Form Center

Community Event Form

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.

   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. Immunizations
    11. Lead Poisoning Prevention
    12. Mental Health Awareness
    13. Nutrition
    14. Opioid Overdose Awareness & Prevention
    15. Pest Management (e.g. lice, bedbugs)
    16. Public Health 101
    17. Rabies
    18. Reproductive Health (e.g. Family Planning, HIV, STI)
    19. Tobacco/Vaping Prevention & Cessation
    20. Women, Infants and Children (WIC)
    21. 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