Request for Outreach Activity Form

Question Title

* 1. Enter your Contact Information.

First Name:

Last Name:

Telephone Number:

Email Address:

Today's Date:

Question Title

* 2. Name of Event.

Question Title

* 3. Location Address.

Question Title

* 4. Date(s) and Time(s) of Outreach Activity.

Date/Time

Date

Time

AM/PM

Question Title

* 5. Type of Outreach Activity Requested.

Presentation

Booth at a Health Fair

Other (please specify)

Question Title

* 6. Topic.

Question Title

* 7. Describe your target audience.

Question Title

* 8. How many people are you expecting to attend?

Number

Question Title

* 9. You will need to provide us with a table and chair?

Yes

Question Title

* 10. What size will the table be?

Question Title

* 11. Will this activity be inside/outside?

Inside

Outside

Question Title

* 12. What happens in the event of rain?

Question Title

* 13. Are electrical outlets available for a PowerPoint Presentation?

Yes

Question Title

* 14. How is this Outreach Activity being Advertised/Promoted?

Newspaper

Radio

Internet

Church Bulletin

Other (please specify)