Event Details

Outreach requests are based on staff availability. In order to match your request with the appropriate department we need information such as location, day and time, approximate number of visitors, etc. Please fill out our outreach form with as much information as possible if you are still in the planning phase for your event.

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* 1. Organization/Agency Name

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* 2. Agency Phone Number

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* 3. Contact Person (First and Last Name)

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* 4. Contact Person Phone Number

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* 5. Contact Person Email Address

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* 6. Event Name

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* 7. Event Date

Date

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* 8. Event Time

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* 9. Location (Building name if applicable)

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* 10. Event Address

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* 11. Event City

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* 12. Will this event be held...

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* 13. Will the following items be provided?

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* 14. Has FDOH-Lake participated in this event before?

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* 15. Target Population

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* 16. Anticipated Number of Participants

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* 17. Event Set-Up Time

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* 18. Is parking available?

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* 19. Driving Instructions

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* 20. Onsite Contact Name

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* 21. Onsite Contact Phone Number

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* 22. Requested Services at Event (Select all that apply)

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* 23. Comments

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