Community Outreach and Education Request Form

Community Outreach and Education Request Form

Alamance County Health Department
Requests must be made at least 30 days prior to the date of the event.
The Alamance County Health Department’s Health Education and Promotion Section staff is deeply committed to serving our community. We will strive to honor as many requests as possible. However, we cannot guarantee that all requests will be accepted, as we are limited by previously scheduled events and/or staff availability. If we cannot meet your needs with our presence at your event but you desire information and brochures regarding our services to distribute yourself, please call (336) 570-6382.
Agency/Organization Name*
Title*
title
Contact Person Name*

First NameLast Name
Email*
example@example.com
Phone*
Fax
Address/Location of Event*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Major Cross Street
Parking Info
Person to Report to at Event*

First NameLast Name
On-site phone or cell # (if different from above)
Description of People attending event*
Estimated number of people who will attend event*
Is this event a new event?

YesNo
If no, how many years in existence?
Date of Event*

MonthDayYear
Date
Time*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Set up Date*

MonthDayYear
Date
Set up Time*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
List information you would like to have presented at the event:*
What are the goals of your event?*
Which of the following will be provided?

Table(s)Chair(s)Canopy
Should be Empty: