Fillable Special Event Request Form

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Special Event Request Form

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  • 12 check-boxes
  • 33 other fields

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Page 1 of 3
North Carolina Department of Transportation
Special Event Request Form
Effective 7/31/15, Revised 7/3/19
This request form is required for non-governmental entities for all special events requiring a road, lane, and/or shoulder
closure, or repurposing a State Highway System facility for something other than its intended use, except where a county or
municipality is regulating the use of the highways in accordance with General Statute §20-169. This form must be submitted
with a formal request to the appropriate Division Engineer(s) at least sixty (60) days prior to the scheduled beginning of the
event. See a listing of the Highway Divisions and their contact information at the following URL:
https://apps.dot.state.nc.us/dot/directory/authenticated/UnitPage.aspx?id=630
Section A: Event Information
Name of Event: ____________________________________________________________________________
Type of Event: ____________________________________________________________________________
County/Counties: ____________________________________________________________________________
City/Cities: ____________________________________________________________________________
Event Date(s): ____________________________________________________________________________
Event Time(s): ____________________________________________________________________________
Primary Sponsoring Organization: _____________________________________________________________________
Anticipated number of participants (estimate): __________
Anticipated number of spectators (estimate): __________
Approximate distance in miles: __________
Requested Action(s): Road Closure* Lane Closure* Shoulder Closure*
(Check all that apply)
Repurposing a State Highway System facility for something other than its intended use
*For closures, anticipated time road/lane/shoulder will actually close: ___________ and re-open: ___________
Section B: Contact Information
Director/Organizer Name: _________________________________ Email: ___________________________________
Mailing Address: ____________________________________________________________________________________
Telephone 1: _____________________ Telephone 2: _____________________ Fax: _______________________
Responsible Local Government: _________________________________________________________________________
Local Government Contact: ____________________________________ Email: _____________________________
Telephone 1: _____________________ Telephone 2: _____________________ Fax: _______________________
Responsible Law Enforcement Agency: ___________________________________________________________________
Law Enforcement Contact: ____________________________________ Email: _____________________________
Telephone 1: _____________________ Telephone 2: _____________________ Fax: _______________________
Page 2 of 3
Section C: Support Material (check list)
The following support documentation must be attached to this request before it will be considered (as applicable following
discussions with the local Highway Division(s))…
1. Detailed location(s) of event including maps indicating proposed route(s) used by the event. Any changes to the
proposed routes shall be submitted as soon as the change is made.
2. Detailed description of the event and how it will affect the route(s) used by the event.
3. Written acknowledgement and approval by all local governments whose jurisdiction the event is being held in.
4. Written acknowledgement and approval by local law enforcement and/or the State Highway Patrol.
5. Type, description, and location of any proposed temporary lane closures/interference, road closures/interference,
traffic control and signing with appropriate maps, sketches, detour routes, and written acknowledgement from the
agency providing the temporary closures/interference, traffic control, and/or signing accepting responsibility for such.
6. Description of notification to residents along the route as a safety and informational service.
7. Waiver modification or insurance (select one)
a. Addition of the State of North Carolina and the North Carolina Department of Transportation into participant
release waivers (see Appendix A for example). A copy of a blank waiver shall be provided.
– OR –
b. Certificate of liability insurance as follows:
• General Liability, Each Occurrence: minimum amount of $1,000,000
• Description field: name and type of the event (as indicated in Section A, above)
• Description field: the State of North Carolina and the North Carolina Department of Transportation named as
additional insured parties (this is at the discretion of the individual insurance company)
• Note – Additional liability insurance may be requested at the discretion of the Department
Section D: Terms and Conditions
The following applies to all approved events…
1. Requestor shall be responsible for proper closure of the lanes/roads according to the Manual on Uniform Traffic Control
Devices (MUTCD).
2. Requestor shall be responsible for providing all necessary traffic control using the appropriate law enforcement
agency/agencies or individuals trained in traffic control as set forth in General Statute §20-114.1.
3. Requestor shall be responsible for notification of all emergency services and other responders of any impending closures
and/or interference.
4. Event shall be supported by, or endorsed by, the local governing body/bodies.
5. If the event is a bicycle race, requestor shall be responsible for following rules and statutes specific to bicycle racing as
provided for in General Statute §20-171.2.
6. Requestor shall ensure that all debris, litter, decorations, and other items associated with the event are removed following
the event.
Section E: Signatures
Requestor Signature: _____________________________________ Date: ________________________
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Page 3 of 3
Appendix A
Example of Including the State of North Carolina and the North Carolina Department of
Transportation in Release Waivers
*** Only required if not submitting a certificate of liability insurance ***
[EVENT NAME]
AGREEMENT TO PARTICIPATE RELEASE WAIVER
In consideration of being allowed to participate in any way in [Organization Name] related events and activities; the
undersigned acknowledges, appreciates and agrees that:
1. The risk of injury from the activities involved in [Event Name] is significant, including the potential for
permanent paralysis and death; and,
2. I knowingly and freely assume all such risks, both known and unknown, even if arising from the negligence
of the releasees or others, and assume full responsibility for my participation; and,
3. I willingly agree to comply with the stated and customary terms and conditions for participation. If,
however, I observe any unusual significant hazard during my participation, I will remove myself from
participation and bring such to the attention of the nearest [Organization Name] representative; and,
4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, hereby release
and hold harmless [Organization Name], their officers, officials, agents and/or employees, volunteers, other
participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and lessors of premises
used to conduct the event.
5. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, hereby
release and hold harmless the State of North Carolina, the North Carolina Department of
Transportation, [County Name] County, [Municipality Name, if applicable], their officers, officials,
agents and/or employees, volunteers.
6. I grant to [Organization Name] my permission to use without charge any and all photographs, video
reproductions or other like kinds of image productions taken during the event.
7. I understand that [Event Name] and its staff are not responsible for the loss, theft, or any damages to
personal property which includes, but is not limited to bicycles, vehicles, tents, trailers, luggage, etc.
8. I understand that I can be removed from the ride at any time for any reason with no refund.
I have read this release of liability and assumption of risk agreement, fully understand its terms, understand that I
have given up substantial rights by signing it, and sign it freely and voluntarily without any inducement.
_________________________________ __________________________________ ______________
Name Signature Date
EXAMPLE
ONLY
EXAMPLE
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EXAMPLE ONLY
EXAMPLE ONLY
EXAMPLE ONLY
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Special Event Request Form

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Completed 9 February 2021

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