Nassau County Department of Health

End of Academic Year Celebrations Notification Form

As per the New York State Department of Health Interim Guidance for End of Academic Year Celebrations, In-Person and Catered Events, Responsible Parties are required to notify the Local Health Department when an event will exceed the State's maximum social gathering limits.

Name of Event: *

Event Address 1: *

Event Address 2:

City: *

State: *

Zip Code: *

Location on Premise: *

Contact First Name: *

Contact Last Name: *

Contact email: *

Contact Phone Number: *

Event Date: *

Event Start Time: *

Event End Time: *

Expected Number of Attendees: *

Expected Number of Event Staff: *

I have read the applicable NY Interim Guidance for Food Services and/or End of Academic Year Celebrations During the COVID-19 State of Emergency.

I must collect the required contact information for attendees including their full name, date of birth, address, email and phone number. These records must be maintained for a minimum of 28 days and made available to State and local health authorities upon request.

I must enforce Screening Testing as required in the applicable Interim Guidance.

I must conduct Health Screenings as required in the applicable Interim Guidance.

Submitted By:

First Name: *

Last Name: *

All fields marked with a red asterisk (*) are required