2. Name of Event*
3. Organization Hosting Event*
4. Est. number attending*
6. Contact Person(s)*
7. Phone Number*
8. Email Address*
10. Event Address*
12. Event City*
13. Event State*
14. Event Zip Code*
16. Does this event require base access?
    -- Select One --YesNo
20. Event Date*
    Event Date
21. Event Time:*
    Event Time: Start Time

    —

    Event Time: End Time

    Please enter event start and end time.

23. Health Materials/Topic*
    -- Select One --Physical Activity Health Management Healthy Eating Stress ManagementOverview of Health Department services Immunizations Chronic DiseaseMental HealthSubstance MisuseDiabetes Prevention
24. Will the event be indoors or outside?*
    -- Select One --InsideOutside
26. Audience*
    -- Select One --ChildrenTeensAdultsSeniors (60+)FamiliesAll Ages
27. Format*
    -- Select One --BoothClass (Interactive)Presentation (Lecture)Education Literature Only (No staff present)
28. Would you like a Mobile Breastfeeding Station?
    -- Select One --YesNo
30. Will food trucks be present?*
    -- Select One --YesNo
31. Would you like COVID-19 vaccines available?*
    -- Select One --YesNo

    Limited to clinic availability. 

33. Items provided at your Facility/location (check all that apply):

    1. Projector/TV
    2. Computer

    1. Tables
    2. Chairs

    1. Electricity
    2. Canopy (if outdoors)
35. Additional Information
39. If available, upload an event flyer or document to give our team additional details.
Leave This Blank:


41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit

* indicates a required field