Program Request – 134 Collaborative

Please note all mandatory fields are marked with asterisk *

Organization Name*

Website

Organization Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Name*

First Last

Phone Number*

Event Name*

Event Type*

Event Description*

Space Preference*

Expected Head Count*

Will anyone under the age of 18 be in attendance?*

Yes
No

Does your organization/group/business have liability insurance coverage?*

Yes
No

Do you have the ability to pay for use of space through grant monies, fee for service, a donation, etc.?*

Yes
No

Will you be charging a fee for admission?*

Yes
No

If yes, specify amount:

Event Schedule Type:*

Event Start and End dates:*

Meeting Date/Time(s):*

I understand that this application is the first step in the process of applying for use of space at Mathewson Street United Methodist Church. My request will be reviewed by the Board of Trustees of Mathewson Street United Methodist Church and the HeadsUp, Inc. Board of Directors. Upon review, I will be notified of the status of my request.

Understanding of terms:*

Agree

Thank you for your interest in using space at MSUMC, Providence, Rhode Island.