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  • Chronic Disease Prevention Event Request

    Please provide a minimum 2-week notice for event requests.


    * Indicates mandatory fields.
    Chronic Disease Prevention Program Request Form

    Requester Information

    Name of Requester: *    Date of Request:   

    Phone: *    Fax:   

    Email:   

    Event Details

    Name of Event: *    Date of Event: *  

    Start Time: *    AM PM  /  End Time: *    AM PM

    Address/Location: *    City: *  

    State: *    Zip code: *  

    Indoor  Outdoor   - If outdoor, is a personal tent needed?   Yes   No

    Type of event:   Focus of event:

    Special instructions:

    Primary Contact (if different from above):

    Phone:     Fax:   

    Email:   

    Expected Participant Demographic

    Expected number of participants: 

    Age Range:    0-17    18-30    31-50    51+  

    Spanish speaker and/or materials needed?   Yes   No

    Special interests or requests?:

     

    Referred from Page: 



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    Health Department

    3950 S. Country Club Road
    Ste. 100
    Tucson, AZ 85714

    (520) 724-7770

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