Event Information
*
indicates a required field
*
Event Name
Event Name is a required field
*
Event Type
Charity Event
Clark County Agency Event
Fair/Carnival
Fire Drill
Fundraiser
Guest Speaker
Other
Safety House
School Visit
Wellness & Health Fair
*
Event Address
Event Address is a required field
*
City
Event City is a required field
*
State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Event State is a required field
*
Zip
Event Zip is a required field
Invalid Event Zip
Location
*
Event Date
Event Date is a required field
*
Event Start Time
*Please select*
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:00
:05
:10
:15
:20
:25
:30
:35
:40
:45
:50
:55
AM
PM
Please make a selection for Event Start time.
*
Event End Time
*Please select*
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:00
:05
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:20
:25
:30
:35
:40
:45
:50
:55
AM
PM
Please make a selection for Event End time.
*
Requested Time Start
(time for CCFD to be there)
*Please select*
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:00
:05
:10
:15
:20
:25
:30
:35
:40
:45
:50
:55
AM
PM
Please make a selection for Requested Time Start.
*
Requested Time End
*Please select*
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:00
:05
:10
:15
:20
:25
:30
:35
:40
:45
:50
:55
AM
PM
Please make a selection for Requested Time End.
*
Reason for Request
(Up to 250 characters. Please provide specific details. This information will be utilized in the approval process.)
Reason for Request is a required field
Contact Information
Organization
Non-Profit Organization?
Yes
If you answered yes to above, please provide your Non-profit organization ID#
*
Contact Name
Contact Name is a required field
*
Address Type
Company
Individual
*
Is address Outside US?
Yes
*
Address
Contact Address is a required field
*
City
Contact City is a required field
*
State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Contact State is a required field
*
Zip
Contact Zip is a required field
Invalid Contact Zip
*
Contact Phone
ex. 702-555-5555
Contact Phone is a required field
Invalid Contact Phone Number
Alternate Phone
ex. 702-555-5555
Invalid Alternate Phone Number
FAX
ex. 702-555-5555
Invalid Fax Number
*
Email
Contact Email is a required field
Invalid Contact Email
If you have an e-mail ending in "@interact.ccsd.net" please use an alternate e-mail address as our system is currently having issues with this domain. We hope to have this resolved soon. Thank you for your patience and understanding.
Atendee Information
*
Number of Adults
Number of Adults is a required field
*
Number of Children
Number of Children is a required field
(type 0 if no children in attendance)
*
Age Range of Children
Age Range of Children is a required field
ex. 10-12 or 0 if no children in attendance
*
Grade Level
not applicable
K
1
2
3
4
5
MS
HS
Grade Level is a required field
If your event is successfully submitted, you will receive confirmation on the next page.