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Event Information
Host Organization:
*
Organization Contact Name:
*
Organization Contact Phone Number:
*
Organization Contact Email
Title of the Event/Activity:
*
Date of the Event:
*
Date of the Event:
Time of the Event:
*
Time of the Event: Start Time
—
Time of the Event: End Time
Location:
Inside
Outside
Both
Event Address:
City:
State:
Zip:
Expected Participants:
Check all that apply
Infants - Young Children
Adolescents
Adults
Low Income/Low Socio-economic status
Non-English Speaking
Expected total attendees:
Type of Event:
Health Fair
Conference/Workshop
Other
If other, please explain:
Is there an associated fee/cost?
Yes
Fee waived
No fee or cost
If there is an associated fee/cost, please list the amount:
What education/information services do you need for your event offered by MCHD?
*
Check all that apply
Asthma
Breast health
General MCHD information
Handwashing
Mammography assistance
Nutrition
Oral health
Personal hygiene
Physical activity
Tobacco prevention/cessation
Other
If other, please explain:
Please provide any additional comments:
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