DeKalb Public Health Mobile Community Outreach and Services Request Form

DeKalb Public Health Mobile Community Outreach and Services Request Form
Thank you for your interest in the services offered by DeKalb Public Health.

Please complete this form if you are interested in requesting a mobile outreach or clinic event at your organization.

Requests for on-site services must be submitted at least two (2) weeks before your event date to allow sufficient time for review, scheduling, and coordination.

Host organizations must be located in DeKalb County, nonprofits, businesses, schools, and community organizations.

Completing this form is the first step in notifying us of your interest; however, submission of this form does not guarantee that your request can be fulfilled.

If you need help with this form, please email dekalb.covid19@dph.ga.gov.

*=questions that are required
Name of organization, employer, or community organization requesting event
What best describes your organization?
Describe the type of organization if not on the list.
Location of the Requested Event.
Host organizations must be in DeKalb County, Georgia.

Fill in the information based on where you are requesting the event take place.
Address

Street Address

Street Address Line 2

CityState

Zip Code
County
Requestor Contact Information
Name

First NameLast Name
Title/role in the organization
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Population(s) You Plan to Serve
What communities does this requested event primarily aim to serve? Select all that apply.

Other
Does this event aim to serve any of the following age groups? Select all that apply.
Note: A parent or guardian must accompany their 5- to 17-year-old
Please provide any other information about the community served by this event.
Requested Event Details
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of the Event
Start Time of Event

Hour Minutes

AM/PM Option
End Time of Event

Hour Minutes

AM/PM Option
Please provide an estimated number of people expected to attend this event.
Of the estimate you provided above, how many do you estimate to be people under the age of 18, requiring parent/guardian consent for services?
What services are you requesting? Please select all that apply.

Other __________________________________________
Does your proposed location have an indoor space where the services could be administered and space for waiting and rest areas?
What role(s) will your organization play in this event? Select all that apply.

Other
Does your proposed location have a large space where we could park a mobile wellness unit and set up waiting and rest areas?
Does your proposed location have access to bathrooms for clinic staff and patients?
Please include any additional information that would be helpful for event planning.
A Healthier You for a Stronger DeKalb
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