Community Outreach Event Request

Event Information

Name of Event: *    Date of Event: *  

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

Set-up Time: *     AM  PM

Address/Location: *    City: *  

  Zip code: *  

Indoor or Outdoor event   - If outdoor, is personal tent(s) needed?:   Yes   No

Type of event: Community   Worksite   Youth   Other  

Focus/Purpose of event: *  

What are you requesting: *   Staff to table an event? Speaker?  Handouts?

If speaker, please specify topic, length of time, whether a powerpoint style is desired, and other details:


Would you like us to provide a vaccination clinic? *   Yes   No

Which vaccine(s):   COVID Flu

Fee to participate?:   No   Yes  

Expected Participant Demographic

Expected number of participants: 

How are you advertising this event?: *  

Would you like this event listed in our web calendar for the public to see?: *   Yes   No

Target Audience Age Range:    All ages    0-5    6-17    18-30    31-50    51+  

Spanish speaker and/or materials needed?:   Yes   No

Community of focus, or special requests?:

Logistics

What equipment or supplies will be provided?: *

	Not needed	Requester will provide	Presenter should bring
Electricity
Laptop
Projector
Table
Chairs

Other agencies or partners participating:

Special instructions:

Requester Information

First Name: *    Last Name: *  

Date of Request:   

Phone: *   

Email: *  

Name of Organization:   

Organization type: Government  Non-Profit  Business  Faith-based  School
Healthcare  Other  If other please elaborate:

Day of Event Contact

Contact Name: *  

Phone: *