Question Title * 1. Enter a Date Date / Time Date OK Question Title * 2. Contact Information: Organization /Agency Name Contact Person (First and Last Name Phone Number Cell Number Fax Number Email Address OK Question Title * 3. Event Information Name of the Event Dates (mm/dd/yy) Time (i.e. 12:00 PM to 2:00 PM) Location (building name if applicable) Event Address Event City OK Question Title * 4. Will this event will be held... Inside Outside OK Question Title * 5. Is there a vendor fee? Yes No OK Question Title * 6. Will tables and chairs be provided? Yes No OK Question Title * 7. Has FDOH-Lake participated in the event before? Yes No OK Question Title * 8. Target Population: Older Adults (65 and older) - Female Adults - Female Families Hispanic / Latino Older Adults (65 and older) – Male Adults - Male Caucasian Other: Older Adults (65 and older) - All Adults - All African American OK Question Title * 9. Anticipated Number of Participants: Less than 100 101-200 201-300 301-400 401-500 501 and above OK Question Title * 10. Please include day of event details, such as set-up time, driving/parking directions, and onsite contact information OK Question Title * 11. What FDOH-Lake services are you requesting? OK Florida Department of Health in Lake County Vision: To be the Healthiest State in the Nation OK DONE
