Block Party Permit: City of Medina

Please complete the information below, print off the form and submit to the City of Medina, Office of the Mayor, 132 N. Elmwood Avenue, Medina, Ohio 44256.

*First Name:
*Last Name:
*Address:
*Phone:
*Date:
*Date of Block Party:
*Location of Block Party:
*Name of Street requesting to block off::
*Name(s), address, and phone #'s of participants::


Please note: the City of Medina no longer provides barricades for block parties. If you are requesting a street(s) to be blocked off, please indicate which street(s) above. You are responsible for blocking the listed street(s). Please be aware that one lane needs to be left open for emergency crews or other residents who need to get through. I have read and fully understand the rules and regulations regarding this permit. Signature of Applicant:__________________________Date:____________ For office use only APPROVED BY: Service Director:_______________________Date:______ Police Chief:__________________________Date:______ Mayor:______________________________Date:_______