Menninger Department of Psychiatry and Behavioral Sciences Community Engagement Form
Name of Organization
*
Primary Contact
*
First Name
Last Name
Primary Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Contact Email
*
example@example.com
Event Name
*
Date(s)
Location
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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 Fair
Community Talk/Discussion
Community Fair
Panel Discussion
Other
Request Type
Health Education
Education Material
Other
Please verify that you are human
*
Submit
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