Address of Block Party:

Block Party Address (This should be the power source location) *

Name of Applicant *

Date of Block Party * If your desired date is not listed in the drop down, there are no more Jumping Jacks available for that date.

Approx # of Children Attending *

On-Site Contact:

Name *

Home Address *

Zip Code *

Email *

Cell Phone #*

Secondary On-Site Contact:

Name *

Email *

Cell Phone #*

I certify that I am requesting a Jumping Jack Inflatable for a residential block party and have read all the rules and regulations. DCASE reserves the right to cancel this agreement if the rules are not met. *