Event Information
*
indicates a required field
*
Event Name
*
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
*
City
*
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
*
Zip
Location
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Event Date
*
Event Start Time
*Please select*
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:00
:05
:10
:15
:20
:25
:30
:35
:40
:45
:50
:55
AM
PM
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Event End Time
*Please select*
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:05
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:35
:40
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:50
:55
AM
PM
*
Requested Time Start
(time for CCFD to be there)
*Please select*
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:00
:05
:10
:15
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:50
:55
AM
PM
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Requested Time End
*Please select*
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:00
:05
:10
:15
:20
:25
:30
:35
:40
:45
:50
:55
AM
PM
*
Reason for Request
(Up to 250 characters. Please provide specific details. This information will be utilized in the approval process.)
Contact Information
Organization
Non-Profit Organization?
Yes
If you answered yes to above, please provide your Non-profit organization ID#
*
Contact Name
*
Address Type
Company
Individual
*
Is address Outside US?
Yes
*
Address
*
City
*
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
*
Zip
*
Contact Phone
ex. 702-555-5555
Alternate Phone
ex. 702-555-5555
FAX
ex. 702-555-5555
*
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 Children
(type 0 if no children in attendance)
*
Age Range of Children
ex. 10-12 or 0 if no children in attendance
*
Grade Level
not applicable
K
1
2
3
4
5
MS
HS
If your event is successfully submitted, you will receive confirmation on the next page.