APPLICATION KIT - Bundaberg Regional Council

NOMINATION FORMYour DetailsCONTACT PERSONCONTACT NUMBERCOMMUNITY GROUP OR BUSINESS NAME (IF APPLICABLE)CONTACT EMAILADDRESSSHIRT SIZEPLEASE CIRCLES M L XL 2XL 3XL 5XLWILL YOU BE AVAILABLE TO ATTEND A SAFETYINDUCTION 30 APRIL 2013? PLEASE CIRCLEYES / NOR&R Checkpoint Fiesta DetailsFOR INDIVIDUALS:Nominate any 2 hour period between 10am – 6pm from 4th May – 2nd June 2013 excluding Mondays.FOR COMMUNITY GROUPS OR BUSINESSES:Nominate any 2 hour period between 10am – 6pm on any of the following Mondays in order of preference -6th, 13th, 20th or 27th May 2013Priority will be given to those most affected by recent disaster events.PREFERENCE 1DATE:TIME:PREFERENCE 2 DATE: TIME:PREFERENCE 3 DATE: TIME:Please provide exact address and location for nominated R&R Checkpoint Fiesta set up and delivery:LOCATION PREFERENCE 1LOCATION PREFERENCE 2NUMBER OF PEOPLE YOU EXPECT TO ATTEND:HOW MANY PROPERTIES AND WHAT STREETS WILL BE INVOLVED IN YOUR AREA:COMMENTSTERMS & CONDITIONS1) Nominations are confirmed based on available dates, venues and Council resources.2) Upon receipt of nomination an acknowledgement is sent within 48 hours and confirmation will be made within 6-10 working days from receipt of application.3) No R&R Checkpoint Fiesta activities will be hosted on private property.4) Successful nominees will be notified by Council staff to assist with organisation of their session.5) Nominees must be Residents of the Bundaberg Local Government Area.6) The decision for selection in delivery, times and dates made by Council is final and no correspondence will be entered into.7) All activities must be conducted in full compliance with all laws and in compliance with the requirements of the relevant authority.8) A respectful and courteous level of conduct is expected at all R&R Checkpoint Fiestas and any person unwilling to comply may be asked to leave the activity.9) Parents/ Legal guardians are responsible for the safety and behaviour of children (Under 18).10) R&R Checkpoint Fiesta activities are not transferrable and cannot be exchanged or redeemed for any other Bundaberg Regional Council Services.11) Bundaberg Regional Council reserves the right to cancel any activity if deemed appropriate to do so.12) Bundaberg Regional Council accepts no liability for any accidents or injuries or damages which may occur during or a result of activities except where they arise asthe direct result of negligence by the Council.13) Privacy Statement: Personal Information collected through this nomination process will be used by Bundaberg Regional Council only for the delivery of this program.Yes, I agree to the conditions stated in the application form and to work with Council in organising anddelivering the R&R Checkpoint Fiesta activitySIGNATURE:DATE:

SIGNATURE REGISTERFOR STREET CLOSUREBy signing below you agree to your street being closed for the delivery of the nominated R&R CheckpointFiesta Activity. If nominating for street closure please make second or third preference a local park location inthe instance a road closure is not possible.NAME ADDRESS CONTACT NUMBER SIGNATURE