The Mississippi Department of Environmental Quality
Please clearly print or type information in its entirety.
Performance requirements are listed on the Watershed Harmony information sheet.
* Please fill in complete address, E-mail, phone number, etc.
Event
Name: ___________________________________________________________________
Event
Purpose:
_________________________________________________________________
Host/Hosting
Group:
____________________________________________________________
Watershed: ____________________________________________________________________
Funding
Source:
________________________________________________________________
*Event
Location:
________________________________________________________________
*Complete street address required for MDEQ purposes.
Event
Date: ____________________ Event Times:
__________________________________ Number
of Teachers: ____________ (MDEQ will provide 1 activity book per
teacher.) Students
Age/Grade: _____________ Number of Students: ____________________________ What
counties will the students represent?
___________________________________________ ______________________________________________________ A host or hostess must
accompany performers from arrival to departure. *Contact
Name:
_________________________________________________________________ *Contact
Address:
_______________________________________________________________ *Work
Phone Number: _________________ Cell Phone Number: _____________________ Please turn on Cell no later than 6:00 a.m. on day of event!
*E-mail
Address:
________________________________________________________________ *Alternate
Contact Person:
________________________________________________________ *Alt.
Contact Work Number: ______________ Alt. Contact Cell Number: _________________ Please turn on Cell no later than 6:00 a.m. on day of event!
*Host/Hostess
to Performers: _______________________________________________________ Directions
to Event/Special Instructions:
_____________________________________________ ______________________________________________________ Please promptly fax or mail this form to us at:
BAYOU TOWN Productions 3166 Road 310, Kiln, MS 39556
Fax/Phone: (228) 586-0479
Contact Person Information