COVID-19 Large Gathering Event Notification Form

Name of Event *

Event Location / Name *

Event is: *

Indoor
Outdoor

Date of Event *

Start Time *

End Time *

Room or Area Name / Description *

Room Capacity (at 100%) *

Expected # of Event Staff *

Expected # of Attendees(must be lesser of 150 persons or 75% of venue capacity indoors or 500 persons or 75% outdoors) *

Location Information *

Address Line 1

Address Line 2

City

State

Zip

Location Contact

First Name *

Phone *

Last Name *

Email *

Name of Caterer (if different)

**Food Service Facilities must have NY Forward Safety Plan completed and available for review**

Event Organizer Contacts

Contact 1 First Name

Contact 1 Phone

Contact 1 Last Name

Contact 1 Email

Contact 2 First Name

Contact 2 Phone

Conatct 2 Last Name

Contact 2 Email

Responsible Party

The responsible party submitting this form must affirm below that all applicable current NYS COVID-19 Executive Orders and Guidance will be followed.

I am the responsible party for the business, organization or event listed. I have reviewed all applicable New York State interim guidance for event activities and operations during the COVID-19 public health emergency and I affirm that I have read and understand my obligation to operate this event in accordance with such guidance. I understand that my event may be subject to inspection by the Ulster County Department of Health to ensure compliance with all provisions of the guidance.

Affirm to Statement *

By checking this box, I agree to the above statement.

Responsible Party First Name *

Responsible Party Phone *

Responsible Party Last Name *

Responsible Party Email

Website