Good Health WINs San Antonio Coalition Partnership Form
Event Information Collection Form
Today's Date
*
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Month
-
Day
Year
Date
Name of Organization/Agency
*
Requested Appearance Date:
*
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Month
-
Day
Year
Date
Name of Event or Program
*
Event Location & Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Time of Event (AM/PM) CST (Include Start and End Times)
*
Hour Minutes
AM
PM
AM/PM Option
Estimated Number of Participants:
*
Primary Event Audience (Check all that apply)
*
School Aged Children
Teens ages 13 - 17
Adults
Seniors
Pregnant Moms
Families
Other
Which Nutrition Service are you interested in? (Check all that apply)
*
Viva Health (Free Nutrition Materials)
Por Vida (Local Restaurant Recognition)
Media Request (TV/Radio Segment)
Nutrition Education Session (Virtual)
Nutrition Education Session (In-Person)
Outreach (Tabling Event)
Cooking Demo
Train the Trainer (Nutrition Series)
Other
Preferred Language
*
English
Spanish
Other
Please provide any additional details pertaining to your event, such as your nutrition services request and/or any special instructions:
Point of Contact:
*
First Name
Last Name
Point of Contact Email:
*
example@example.com
Point of Contact Phone:
*
Please enter a valid phone number.
Please add any any flyers or documents you would like to share:
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I understand that completing this form does not guarantee or confirm the appearance of Good Health Wins San Antonio Coalition program staff at your event.*I understand that data may be collected when administering pre-post surveys from nutrition education sessions. I understand that this form is not a contract or agreement
*
I agree
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