Please submit your request 4 weeks before your event. Please allow 10 working days for review of your request. You will be contacted after the review is complete. You must have JavaScript enabled to use this form. Your Information Name Business/Organization Phone E-Mail Event Information Title of Event Date of Event Event Information Type of Event Type of Event - Select -Health Fair/TablingPresentation/Speaking EngagementOther… Please Specify Event Set-up Time Event Start Time Event End Time Address of Event Address City/Town ZIP/Postal Code Number of attendees expected Is this event indoors, outdoors, or virtual? - Select -indoors outdoorsvirtual Target Audience (select all that apply) Adults Children Employees Families Older Adults Teens/Young Adults Others… Enter others… What information or activities do you want us to provide? (select all that apply) Animal to Human Disease Education Breastfeeding Education Clinical Services Education Emergancy Environmental Health (Air Quality, Water Quality, Radon) Lead in Home (prevention and reduction) Food Safety Public Health 101 Presentation Recycling Infomation Sexual Health Education/Healthy Relationships Tobacco and Nicotine Education Nutrition Education/Food Assistance Substance Use Resources/Education Positive Youth/Teen Activities Maternal Child Health/Child Fatality Prevention Others… Enter others… Submit
