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Brunswick County Health Services Outreach and Services Request Form

Brunswick County Health Services desires to collaborate with partners throughout the community, such as work sites, schools, faith based community groups, families etc. to promote healthy lifestyles. Our staff can provide workshops and presentations on a variety of topics promoting community health and well-being. We will be pleased to provide requested services for your organization or event, dependent on the availability of staff. 
1.Requesting Organization/Agency(Required.)
2.Contact Person(Required.)
3.Phone
4.Email Address(Required.)
5.Please select the services and or topics being requested.(Required.)
6.Event Name
7.Please provide a detailed description of the event and/or the services you are requesting from Brunswick County Health Services. For example, expected number of participants, desired outcomes etc.
Please also include the names of any additional agencies you will be inviting to your event. This information will assist Health Services h staff in planning and preparing for the event.(Required.)
8.Event Date(s)(Required.)
9.Time of Event(Required.)
10.Event Location Address:(Required.)
11.Please select the equipment you have available for Health Services Staff at the event location:(Required.)
12.Is there anything else you would like us to know about your event?