Request Public Education Services

Name(Required)

First Last

Phone(Required)

Email(Required)

Date of Event(Required)

Time of Event(Required)

Location of Event(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Estimated children aged 0-11 years old(Required)

Estimated youth aged 12-17 years old(Required)

Estimated Adults aged 18-59 years old(Required)

Estimated Older Adults 60+(Required)

Organization/Group Name

Comments

Collection of Personal Information

Personal information collected on this form is collected pursuant to the Municipal Act, 2001, s. 11(1), and will only be used for the purpose for which it is collected, and will not be distributed or used by the Town of Ajax for any other purpose. Questions about this collection may be directed to the Town of Ajax Records and Freedom of Information Coordinator at 65 Harwood Avenue South, Ajax, Ontario, L1S 2H9 or 905-683-4550. Learn more about the Town of Ajax's Privacy Policy (https://ajax.ca/privacy/). Accessibility If you require this form in an alternative format, please contact the Town of Ajax Accessibility Coordinator, at 905-683-4550, or by e-mail at contactus@ajax.ca (mailto:contactus@ajax.ca).