Barbershop Form

By submitting this form, I, the Owner/Representative of this barbershop, agree to provide my barbershop as an official location for the Indiana Black Barbershop Health Initiative. Volunteers and other personnel associated with the event can have access to my shop starting at 8:30 AM, on the pre-designated by community, Saturday in April, 2020 and may remain until all activities (monitoring of clients, clean-up, and equipment/supply retrieval) have concluded on the day of the event. I also grant permission to receive the delivery of materials and supplies if necessary, associated with the event prior to the event which may remain on my premises until the Monday immediately following the event.

Barbershop Name:

Owner's Name:

Manager Name:

Address:

Phone Number:

Email Address:

Sq. Footage of Shop:

# of Barbers & T-Shirt Sizes:

(M)

(LG)

(XLG)

(2X)

(3X)

(4X)

Location to place a Table of informational handouts for initiative.

Onsite Parking Available?

Any Additional Comments, Questions or Concerns:

Intended Partition: