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2. Disclaimer
   Information submitted on this form will be sent via unsecured email. To protect sensitive information, do not enter the following items or similar information on this form: Social Security numbers, driver’s license numbers, bank account information, routing numbers, credit card numbers, medical information, passport numbers, and passwords. Please review our privacy policy located at www.jeffco.us/privacy. By submitting this form, you acknowledge and accept the terms listed in the privacy policy.
4. All Special Activity applications for events to be held in the 2022 calendar year are due no later than October 8, 2021 at 11:59pm and responses to applicants will be issued no later than December 1, 2021. Please also read the information contained within the Permits and Reservations web page regarding fees, insurance and conditions associated with a park permit agreement before submitting this form.
6. Name of Event*
7. Company or Group Name*
9. Name of Park Requested*
   -- Select One --All Open Space ParksAlderfer/Three Sisters ParkApex ParkBeaver Ranch ParkCentennial Cone ParkClear Creek Canyon ParkCrown Hill ParkDeer Creek Canyon ParkElk Meadow ParkFlying J Ranch ParkHildebrand Ranch ParkHiwan Heritage ParkLair o' the Bear ParkLookout Mountain Nature Center and PreserveMatthews/Winters ParkMeyer Ranch ParkMount Falcon ParkMount Galbraith ParkNorth Table Mountain ParkPine Valley Ranch ParkReynolds ParkSouth Table Mountain ParkSouth Valley ParkVan Bibber ParkWelchester Tree Grant ParkWhite Ranch ParkWindy Saddle ParkOther
10. If "Other", please describe
12. Name of Specific Site, Trails, or Area Within Park Requested*
14. Date of Activity*
    Date of Activity
16. Start Time of Activity*
    Start Time of Activity
17. End Time of Activity*
    End Time of Activity
19. Anticipated Number of Participants*
20. Anticipated Number of Vehicles*
22. Detailed Description of Proposed Activity*
    Please be as thorough as possible
24. What assistance is requested or necessary of JCOS staff?*
26. Please Explain How This Event Supports the Mission of JCOS*
    Mission available here: https://www.jeffco.us/1571/About-Us
30. Contact Info. of Event Organizer
32. First Name*
33. Last Name*
35. Address*
37. Address Line 2
39. City*
40. State*
41. Zip Code*
42. Country*
44. Phone Number *
46. Email Address*
50. Contact Info. of Responsible Person on Site During Event
52. First Name*
53. Last Name*
55. Phone Number*
56. Email Address*
60. Will your activity impact adjacent public right-of-way, private properties, or surrounding landowners or businesses?*
    -- Select One --YesNo
62. If "yes", please describe
64. Will a fee be collected?*
    -- Select One --YesNo
65. If so, how much is the participant fee?
66. Are you an insured government agency?*
    -- Select One --YesNo
68. Type of Organization*
    -- Select One --Non-profitFor ProfitGovernmentOther
69. Non-profit EIN or ID Number*

    If non-profit, please enter your state issued EIN or Registration ID and attach a copy of your state issued Certificate of Good Standing in the next field

70. Non-profit Certificate of Good Standing

    If you are applying as a non-profit, a current certificate of good standing must be attached. Failure to attach this document will result in an incomplete application and will be discarded. 

72. Will activity be publicized on radio, TV, website, in newspapers or posted in public places?*
    -- Select One --YesNo
74. Please Describe and Insert Links to all Places of Online Advertisement
78. Documentation
80. Course Map
81. Parking Management Plan
82. Certificate of Insurance
84. Emergency Management Plan
85. Site Plan
86. Other
90. Electronic Signature Agreement*

    I understand that I am responsible and accountable for all aspects of this event including, but not limited to: all agreed upon Terms and Conditions of approved permit, damage to trails, damage to facilities, ensuring that all participants abide by all JCOS Park Regulations outside of those which are specifically addressed in issued permit, and cancelation of event if adverse conditions are present.

    1. I agree.
92. Signature of Applicant*
    I (we) hereby swear or affirm, under penalty of perjury, that the information given here is true and correct. The typed signature below indicates this individual, or the legal entity the individual represents (as applicable), accepts responsibility for the activity and agrees to the terms and conditions of this agreement.
93. Date*
    Date
95. Receive a Copy of Your Submission
    By checking the box below, you will receive a copy of the application you are submitting; however, this does not mean that your application has been approved. We will contact you no later than December 1st, 2020 to let you know the status of your application.
Leave This Blank:


104. 1. Receive an email copy of this form.
105. Email address

     This field is not part of the form submission.

106. Submit

* indicates a required field