LCEMA Event Request Form Question Title * 1. Your Name Question Title * 2. Email Question Title * 3. Phone Number Question Title * 4. Event Name Question Title * 5. Event Date Date / Time Date Question Title * 6. Is this a reoccurring/yearly event? If yes, please indicate the annual dates of the event in the space provided below. Yes No Annual Dates of Event Question Title * 7. Organizing Agency Question Title * 8. Event Start and End Time Date / Time Date Time AM/PM - AM PM Question Title * 9. Anticipated Number of Attendees Question Title * 10. Event Location Address City State Zip Code Question Title * 11. What is the target audience for this event? Question Title * 12. Will tables, chairs, and a tent/canopy be provided? If yes, please indicate how many of each item below. Tables Chairs Tent/Canopy Question Title * 13. Will there be access to electricity at this event? Yes No Question Title * 14. What topics would you most like to learn about or have LCEMA discuss at this event? Question Title * 15. Are there any special educational materials that you request LCEMA bring to the event? For example, materials in Spanish, for children, seniors, etc. Question Title * 16. Please use the box below to provide any additional details that will help LCEMA better prepare for this event. Done