Community Health Engagement Request Form
The Macon-Bibb County Health Department participates in numerous community health fairs throughout Bibb County. By partnering with local organizations, we aspire to raise health awareness and promote access to healthcare in our community.
Please complete this form 2 months before the event date.
We will acknowledge your request within one week of our receipt. Our participation and services provided will be based on the availability of our staff and resources. We will contact you to confirm or decline our participation no later than one month prior to your event date.
Host Organization Name
*
Contact Name
*
First Name
Last Name
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Contact Email
*
example@example.com
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
Target Audience
*
(Ages, languages, at-risk population, etc.)
Expected Number of Attendees
*
Services Requested (Check all that apply):
*
Health Education Information
Blood Pressure Screenings
Body Fat Composition Screenings
Safe Kids
Educational Materials Only - Presence Not Requested
Other
Additional information you would like to add about the event:
Ex: Do we need to bring our own table and chairs? Is this an outdoor event?
If we are unable to attend the event, we may be able to provide information about health topics and Macon-Bibb County Health Department services.
If we are not able to attend, would you like us to send you this information?
Yes
No
If yes, please indicate the language requested for the materials:
*
English
Spanish
Both
Submit
Should be Empty: