Required fields are marked with asterisks (*)

Cowan Community Health Hub Room Request

Name (First and Last)

Organization/Department

Address (Street address, P.O. Box, R.R. #, Apt/Suite)

City

Postal Code

Phone Number (s)

Please provide date of event/function

Start time of event/function:

End time of event/function

Expected Attendance

Is the event for youth ages 13-17?

Yes

Pick facility you would like to book:

Bachir & Yerex Community Room (capacity 126; seating for 72 people)

Wilkin Board Room (capacity 26; seating for 14 people)

Liability insurance is mandatory for all rentals booked by the County of Brant. This location requires liability insurance at an additional cost through a third party provider. Please confirm you will complete this.

Yes. Minimum 2 million liability insurance is required. The Corporation of the County of Brant and Brant Municipal Enterprise Inc. are to be added as an additional insured.

Will you be bringing any rented items? eg. glasses, linens, etc

Yes

Please provide any additional information about your event/function

Please provide your signature

Clear