Community Outreach and Request Form

2. 
3. 
4. 
6. Name of Event
7. Organization Hosting Event
9. Contact Person(s)
10. Telephone #
12. Email
16. Event Location/Address
18. City
19. State
20. Zip Code
22. Event Date/Time
    Event Date/Time

    Event Date/Time
24. Service Being Requested
    -- Select One --Adolescent Health - Mindfulness, Stress, and AnxietyAdolescent Health - Reproductive HealthAdolescent Health - Social MediaAdult Health - DiabetesAdult Health - Workplace WellnessHealth Fair - Blood Pressure, BMI, or A1CNutrition - Eating DisordersNutrition - Healthy EatingOtherPhysical ActivitySubstance Use - Alcohol, Opioids, or MarijuanaSubstance Use - Juuling, Vaping, or Tobacco Use
26. Format

    1. Booth
    2. Class (Interactive)
    3. Educational Literature Only (no RCHD staff present)

    1. Presentation (Lecture)
    2. Other
28. Other Request
30. Estimated Number of Participants
32. Available at Your Facility/Location (check all that apply):

    1. Projector
    2. Screen
    3. Computer

    1. Tables
    2. Chairs
    3. Access to outlet
Leave This Blank:


34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit

* indicates a required field