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

    1. New
    2. Returning
15. Date*
    Date
16. Start Time*
    Start Time
17. End Time*
    End Time
19. Block Party Location*
21. Please provide the contact information and addresses of two adjacent neighbours who support the block party and consent to being alternate block party contacts.
23. First Name*
24. Last Name*
26. Address*
28. City*
29. State*
30. Postal Code*
34. First Name*
35. Last Name*
37. Address*
39. City*
40. State*
41. Postal Code*
43. Please provide a list of addresses or unit/apartment numbers of neighbourhood residents who will be invited to attend the block party.*
45. Approximately, how many people will be attending the block party?*

    *Block parties expecting more than 250 people are not eligible for this program.

47. I am applying for the

    1. Soccer Block Party with free screen rental
    2. Soccer Block Party ($500 grant)
    3. Block Party ($150 grant)
49. Soccer Block Party with free screen rental

    • I have WiFi or internet to broadcast the soccer game 
    • Screen rentals are only available to block parties with minimum 50 people. I will have minimum 50 people at my block party 
    • I consent that my name, email and phone number will be shared with the supplier to coordinate the set up and removal of the rental screen

    1. I consent
51. Soccer Block Party

    • I am requesting a free Activity kit that includes craft supplies 
    • I am requesting a Playkit (subject to availability) 
    • In order to be eligible for the $500 grant, I agree that my block party will have minimum 30 people

    1. I consent
53. 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.
    
    

55. 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.

56. 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.

58. 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. 

    All approved road closures require heavy vehicle barricades parked behind the barricades to block the entrance.

60. Will your block party require road closures?*

    1. Yes

    1. No
61. 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.
63. Collection and 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 Heidi Hughes – City of Coquitlam Tourism and Visitor Economic Manager by email or call 604-927-3699.

    I understand by submitting this form I am consenting to the collection, storage, use and disclosure of my personal information for the purposes of the Block Party-FIFA World Cup Competition watch party Program in accordance with the Freedom of Information and Protection of Privacy Act. I understand that my personal information will be disclosed to third-party service providers for the purpose of processing the form. Questions may be directed Heidi Hughes – City of Coquitlam Tourism and Visitor Economic Manager by email or call 604-927-3699.

    1. I consent
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65. 1. Receive an email copy of this form.
66. Email address

    This field is not part of the form submission.

67. Submit

* indicates a required field