Putnam County Department of Health Request for a Community Event

Request for a Community Event

Putnam County Department of Health | Please complete the below form for a community event at least two to four weeks prior to the event date. Requests will be considered on a case-by-case basis pending staff availability.
Event Name
Type of Event
i.e. health fair, community day
Event Date

MonthDayYear
Date
Start Time

Hour Minutes

AM/PM Option
End Time

Hour Minutes

AM/PM Option
R.S.V.P. by
Location of this event / Address*

Street Address

Street Address Line 2

CityState

Zip Code
Is this event*

INSIDEOUTSIDE
Which of the following will be provided*

TentTablesChairsTableclothElectricityWi-FiOther
Expected Audience*
List the health topics of interest for this event*
Health Goal/Purpose*
Organization in charge of event*
Contact Person*

First NameLast Name
Email*
Please re-enter your email
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Backup Person Day of Event
Back up Person's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Should be Empty: