MOCHA Buffalo Community Outreach Request Form

MOCHA Buffalo Community Outreach Request Form
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
What is the name of your organization*
Date of your event*

MonthDayYear
Date
Time of your event*

Hour Minutes

AM/PM Option
What is your event called/what is the occasion?*
Where is your event located?*
If you don't know the location yes, put "TBD"
What would you like us to bring?*

Condoms (+ lube, internal condoms, dental dams, etc.)Swag (T-shirts, sweatshirts, pens, keychains, etc.)Rack cardsBusiness cardsPostersSTI prevention literatureFlag standMOCHA calendars/event flyersOther (please specify)
Are you able to provide a table/tables?*

YesNoN/A
Would you like us to conduct STI testing?*

Yes (if you request STI testing, we require a private bathroom to conduct it)No
What is your target demographic?*
Why do you believe MOCHA should be at your event?*
How did you hear about us?*

Social Media (Instagram, Facebook)Partner organization (Evergreen, Pride Center, Community Access Services)AdvertisementFriend/familyCurrent or former MOCHA patientAttended a past MOCHA eventAttended an event MOCHA tabledExternal organization referralOther (please specify)
Should be Empty: