"Pete" Mobile Community Outreach Event Request Form
Event Name
*
Event Date
*
-
Month
-
Day
Year
Date
Event Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Event Start Time
*
Hour Minutes
AM
PM
AM/PM Option
Event End Time
*
Hour Minutes
AM
PM
AM/PM Option
Number of Attendees Expected:
*
Service Requested
*
Developmental Disabilities Services
Behavioral Health Services
Community Outreach Education/Awareness
HIV/STI Testing
Safe Use Education/Supplies
Health Screening
Health Education
Other
Indoor Accomodations Available
Confidential Counseling Space
Medical Exam Room
Blood Draw Station
Table
Chairs
Other
Event Flyer Upload
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Choose a file
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Additional Information
Event Point of Contact
*
First Name
Last Name
Event Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Event Point of Contact Email
*
example@example.com
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Yes
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If yes, what type of Marketing Support?:
Social Media
Newspaper
Radio
Billboard
Eventbrite
Other
Additional Information
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