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2. Main Contact Name*
3. Daytime Phone Number*
4. Email*
6. Address*
8. City*
9. State*
10. Postal Code*
12. Is this a new or returning block party?*

    1. New
    2. Returning
13. Date*
    Date
14. Start Time*
    Start Time
15. End Time*
    End Time
17. Block Party Location*
19. Please provide the contact information and addresses of two adjacent neighbours who support the block party and consent to being alternate block party contacts.
21. First Name*
22. Last Name*
24. Address*
26. City*
27. State*
28. Postal Code*
32. First Name*
33. Last Name*
35. Address*
37. City*
38. State*
39. Postal Code*
41. Please provide a list of addresses or unit/apartment numbers of neighbourhood residents who will be invited to attend the block party.*
43. Approximately, how many people will be attending the block party?*
45. Do you want to rent a Block Party Play Kit for your block party?*

    1. Yes
    2. No

    The play kits are available on a first-come, first-served basis. The contents of each bag may differ slightly but typically includes balls, frisbees, cones, a ball and scoop, and a rubber chicken.

47. Will there be outdoor amplified sound? For example, music played through speakers.

    1. Yes
    2. No

    Note: Any amplified outdoor sound must end by 10 pm.

48. Do you want to have fireworks at your block party?

    1. Yes
    2. No

    If Yes, a Fireworks Permit is required from Coquitlam Fire and Rescue.

50. Road Closure Request
    A road closure is required for any block party that takes place on a City of Coquitlam road including cul-de-sacs, lanes and widened road areas.
52. Will your block party require road closures?*

    1. Yes

    1. No
53. Please indicate the name of the road you would like closed. Also, please indicate where you would like the road closure to begin and end using addresses or cross-roads.
55. Block Party Grant Request
57. Will your block party be applying for the $150 Block Party Grant?*

    1. Yes

    1. No
59. Collection & Use of Personal Information*

    By checking "I consent" you are consenting to the voluntarily collection and use of your personal information in accordance with Section 26(d) of the Freedom of Information and Protection of Privacy Act. The information provided by you will be used solely for the purpose of registering for Block Parties. Your information will not be used for any other purpose. If you have any questions about the collection, storage, correction and/or use of your personal information please contact Karen Basi - City of Coquitlam Cultural Services Manager at 604-927-3599.

    1. I consent
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61. 1. Receive an email copy of this form.
62. Email address

    This field is not part of the form submission.

63. Submit

* indicates a required field