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FLORIDA DEPARTMENT OF HEALTH — INDIAN RIVER COUNTY <br />Wabasso <br />8445 64'" Avenue, Wabasso, FL 32970 <br />PHONE: 772-794-7480 <br />E-MAIL: Margaret.kearney@flhealth.gov <br />FACILITY USE AGREEMENT <br />FOR OFFICE USE <br />ONLY <br />Database <br />Calendar <br />Event ID <br />Entered By <br />CONTACT INFORMATION (REQU <br />Requesting Organization (User) Type of Organization <br />Representative Name <br />E -Mail Address <br />Phone Number <br />Extension <br />CONTACT INFORMATION (MUST BE PRESENT DURING ENTIRE EVENT) <br />Representative Name <br />E -Mail Address <br />Phone Number <br />Extension <br />EVENT DETAILS <br />Type of Event <br />Date of Event <br />ft of Days* <br /># of Participants" <br />*A separate Facility Use Agreement will be required for events scheduled on non-consecutive days. <br />SETUPICLEANUP TIME <br />EVENT TIME (FOR PARTICIPANTS) <br />Start (no earlier than 8:00 a.m.) AM <br />LL PM <br />Start (no earlier than 8:00 a.m.) ❑ <br />❑ <br />AM 4 <br />.PM <br />End (no later than 5:00 p.m.) ❑ AM <br />❑ PM <br />End (no later than 4:30 p.m.) ❑ <br />Evening times are available as staffing permits ❑ <br />AM <br />PM <br />