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Community Engagement Activity Form

Request to participate in an activity.

Please complete the form below to submit your request for consideration.
Requests must align with and support the promotion of access to health, health education, and foster community engagement. Generally, a request must meet the following guidelines: 

• 60-day notice for health fairs, cultural events, and festivals 
• 90-day notice for health awareness campaigns 

Note: Consideration may be given in special circumstances for events with shorter notice
After You Submit this Form
Email questions or any supplemental material to communityengagement@eriefamilyhealth.org. A response will be provided within 7-10 business days.

1.What is the name of the organization making the request?
2.What is the name of a good contact person at this organization?
3.What is their email address?
4.Please list the organization address here.
5.Please list the organization's phone number.
6.What is the organization's website?
7.Type of event
8.Please describe the event, and state its purpose here.
9.What is the deadline for participation?
10.What is the format for this event?
11.What is the type of audience for this event?
12.Is this event open to the public?
13.Can we publicize this event?
14.What are the virtual platform(s) for the event?
15.What are your social media handles and hashtags for this event?
16.Please tell us any additional information about this event.
17.Who is your main contact at Erie Family Health Centers?
Current Progress,
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