Community Event Request
Please fill out all applicable fields.
Today's Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Email Address
example@example.com
Name of Organization
*
Name of Event:
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Event Date:
*
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Event Start and End Time:
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Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Total 0.0
Event Location
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Event Start Time:
*
Hour Minutes
AM
PM
AM/PM Option
Back
Next
Please provide brief description of event
*
Event flyer (if available)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Event Service Request(s)
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Presentation
Tabling
Health Screenings
Flu Vaccination
Promotional Items
Other
Please describe in detail the service(s) / health screening(s) you are requesting.
*
Is the event indoor or outdoor?
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Indoor
Outdoor
Set Up Requirements- Will Charter Oak need to bring the following:
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Tent
Table
Chairs
Describe the anticipated audience.
*
Describe the anticipated audience.
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Adults
Adult Female
Adult Male
Elderly
Children
Teenagers
Homeless
Other
Anticipated number of attendees.
*
Please identify other healthcare organizations that will be in attendance and services they will provide during the event.
*
Submit
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