Department of Family and Community Medicine

Department of Family and Community Medicine - Community Request Form
Family and Community Medicine's Community Engagement & Health Equity Committee and department volunteers participate in health fairs and outreach opportunities throughout Greater Houston. Complete the form to submit a request for our committee's involvement at your event.
Name of Organization*
Primary Contact*

First NameLast Name
Primary Contact Phone Number*
Please enter a valid phone number.
Primary Contact Email*
example@example.com
Event Name*
Location*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date(s)*
Time of Event*
Number of people estimated to attend*
Primary language of attendees, if other than English
Additional Collaborators or Major Sponsors
Event Type*

Health fairCommunity talk/discussionSports eventCommunity fairPanel discussionEvent hosted by a religious organizationFundraiser/donation driveOther
Request Type*

Health screeningHealth educationEducation materialsOther
Please specify the type of screening(s) requested*
Please specify the education topic(s)*
Please specify the type(s) of materials requested and topic(s)*
Please specify other request(s)*
Should be Empty:

Department of Family and Community Medicine - Community Request Form