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2. Contact Information
4. First Name*
5. Last Name*
7. Organization*
8. Job Title*
10. Email Address*
11. Phone Number*
13. Request Details
15. Event Name*
17. Purpose of Event*
19. Physical Address of Event*

    (location where the lactation tent will be set up)

21. Date Tent is Needed*
    Date Tent is Needed
22. Timeframe Tent is Needed*
    Timeframe Tent is Needed Start Time

    —

    Timeframe Tent is Needed End Time
24. Will the tent be used indoors or outdoors for this event?*

    1. Indoors
    2. Outdoors
26. First and Last Name of Person Who Will be Onsite with the Tent*
28. Email Address of Person Who Will be Onsite with the Tent*
30. Phone Number of Person Who Will be Onsite with the Tent*
32. Additional Comments/Notes
34. Drop Off & Pick Up

    The lactation tent will need to be picked up and dropped off by the requesting organization at the Benton County Public Health office located at 531 Dewey Street Foley, MN 56329 (Door #5) between Monday through Friday 8:00 AM to 4:30 PM.

36. Date Tent Will Be Picked Up*
    Date Tent Will Be Picked Up

    Date Tent Will Be Picked Up
37. Time Tent Will Be Picked Up*
    Time Tent Will Be Picked Up

    Time Tent Will Be Picked Up
39. Date Tent Will Be Returned*
    Date Tent Will Be Returned
40. Time Tent Will Be Returned*
    Time Tent Will Be Returned
42. Agreement
44. 1.*

    1. I agree to indemnify, hold harmless and defend Benton County, its officers and employees (collectively “Benton County”) against any and all liability, loss, costs, damages, expenses, claims or actions, including attorneys’ fees which Benton County may hereafter sustain, incur or be required to pay, arising out of any claim of mine, my agents, heirs, or successors, resulting from my free and voluntary use of the lactation tent.
46. 2.*

    1. I agree to follow the guidelines for the set up, maintenance, and take down of the lactation tent provided by Benton County. The purpose of the tent will be to provide a comfortable and private space for community members for lactation. The requesting organization's staff, event staff and/or volunteers will ensure that all guidelines, recommendations, and standards for the lactation tent are met. Please see the lactation tent guide for more information.
48. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) you will abide by all terms of the lactation tent on this request form and in the lactation tent guide 2) your request will not be signed in the sense of a traditional paper document, and 3) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature.

    1. I agree.
50. Electronic Signature
Leave This Blank:


52. 1. Receive an email copy of this form.
53. Email address

    This field is not part of the form submission.

54. Submit

* indicates a required field