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2. 

4. Thank you for your interest in having Tri-County Health Department at your upcoming event. Please use this form to tell us about your event. We appreciate as much notice as possible and would prefer the request be made two weeks in advance. This will improve our ability to meet your needs; however, it does not guarantee a presenter will be available to attend your event. You will receive an email or phone call accepting or declining your invitation within 7–10 days of submitting this form.

6. Contact Person Information
8. First Name
9. Last Name
11. Phone Number
12. E-mail Address
16. Sponsoring Organization Information
18. Organization Name
22. Event Information
24. Is Your Event:

    1. A Community Class
    2. A Health Fair
    3. Other
26. If Other Please Describe
28. Brief Description of Your Event
30. Is There A Fee For Our Participation In Your Event?

    1. Yes
    2. No
31. Would You Like:

    1. A Tri-County Health Department Representative
    2. Educational Materials/Brochures Only
33. Event Date
    Event Date
35. Event Dates (If more than one day)
    Event Dates (If more than one day) Start Date

    —

    Event Dates (If more than one day) End Date
37. Event Set-Up Time
    Event Set-Up Time
38. Event Start Time
    Event Start Time
39. Event End Time
    Event End Time
41. Event Address
42. Event City
43. Event Zip Code
45. Number of Attendees Expected
46. Will Attendees Be Charged For The Event?

    1. Yes
    2. No
48. Parking Instructions
50. Target Audience

    (please check all that apply)

    1. Infant/Toddler
    2. Children
    3. Teens 13-18
    4. Young Adults 19-25
    5. Adults 26-55
    6. Older Adults 55+
    7. Staff/Employees
    8. Students
    9. Other
52. If Other, Please Specify
54. Event Will Be Held

    (please check all that apply)

    1. Indoor - temperature controlled
    2. Indoor - not temperature controlled
    3. Outdoor
    4. Rain or shine
    5. Under Pavillion
56. Item Provided By Event

    (please check all that apply)

    1. Chairs
    2. Tables
    3. Tents
    4. TCHD requested to bring own items for set-up
    5. Other
58. If Other, Please Specify
60. Indicate Equipment Available

    please check all that apply)

    1. Access to WiFi
    2. Access to Electricity
    3. Computer with Presentation Software
    4. Projection Capabilities
    5. Extension Cord(s)
    6. Wireless Presentation Clicker
    7. Other
62. If Other, Please Specify
64. Please Indicate Which Topics You Are Requesting A Presenter Or Information About

    (please check all that apply)

    1. Breastfeeding
    2. Diabetes Education
    3. Disaster/Emergency Preparedness
    4. Disease Prevention & Control
    5. Food Safety
    6. Hand Washing
    7. Health Care Access (e.g. Medicaid enrollment, finding a medical home)
    8. Healthy Aging
    9. Healthy Beverages
    10. Lead Poisoning Prevention
    11. Mental Health Awareness
    12. Nutrition
    13. Opioid Overdose Awareness & Prevention
    14. Pest Management (e.g. lice, bedbugs)
    15. Public Health 101
    16. Rabies
    17. Reproductive Health (e.g. Family Planning, HIV, STI)
    18. Tobacco/Vaping Prevention & Cessation
    19. Vaccine Clinic for COVID-19 Vaccines
    20. Vaccine Clinic for Flu Vaccines
    21. Vaccine Clinic for Routine Childhood/Adult Vaccines
    22. Vaccine Education & Information for COVID-19 Vaccines
    23. Vaccine Education & Information for Flu Vaccines
    24. Vaccine Education & Information for Routine Childhood/Adult Vaccines
    25. Women, Infants & Children (WIC)
    26. Other
66. If Other, Please Specify
68. What Type Of Advertising And Promotion Will Be Done To Promote This Event?
70. Additional Information Relevant To Event
Leave This Blank:


72. 1. Receive an email copy of this form.
73. Email address

    This field is not part of the form submission.

74. Submit

* indicates a required field