Grace Community Health Fair Request
Please note:
Events outside of Baltimore City may be assessed a flat fee
Restrictions and/or limitations on locations outside of Baltimore City
Please request 6-8 weeks prior to date of event
Completion of this application does not guarantee participation in this event.
Participation is based on staff availability.
Please call 410-362-3804 for any questions about this form
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Fax
Event Date
*
-
Month
-
Day
Year
Date
Event Start Time
*
Hour Minutes
AM
PM
AM/PM Option
Event End Time
*
Hour Minutes
AM
PM
AM/PM Option
Sponsoring Organization
*
Name of Event
*
Address of Event
*
Location
Inside
Outside
Special Considerations: (Set up time/special restrictions or notes)
Expected # of Attendees
*
Target Audience
*
Supplies available at site:
Tables
Chairs
Electrical Outlet
Food/refreshments
Water
Brief description of event:
Please indicate service/education needed:
Screening Type:
Blood Pressure
Diabetes
Cholesterol
Other
Education Topics:
Geriatric Health
Chronic Disease Management
Tobacco Cessation
Other
Submit
Should be Empty: