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2. Event Information
4. Host Organization:*
5. Organization Contact Name:*
7. Organization Contact Phone Number:*
8. Organization Contact Email
10. Title of the Event/Activity:*
12. Date of the Event:*
    Date of the Event:
13. Time of the Event:*
    Time of the Event: Start Time

    —

    Time of the Event: End Time
14. Location:

    1. Inside
    2. Outside
    3. Both
16. Event Address:
18. City:
19. State:
20. Zip:
22. Expected Participants:

    Check all that apply

    1. Infants - Young Children
    2. Adolescents
    3. Adults
    4. Low Income/Low Socio-economic status
    5. Non-English Speaking
23. Expected total attendees:
25. Type of Event:

    1. Health Fair
    2. Conference/Workshop
    3. Other
26. If other, please explain:
28. Is there an associated fee/cost?

    1. Yes
    2. Fee waived
    3. No fee or cost
29. If there is an associated fee/cost, please list the amount:
31. What education/information services do you need for your event offered by MCHD?*

    Check all that apply

    1. Asthma
    2. Breast health
    3. General MCHD information

    1. Handwashing
    2. Mammography assistance
    3. Nutrition

    1. Oral health
    2. Personal hygiene
    3. Physical activity

    1. Tobacco prevention/cessation
    2. Other
33. If other, please explain:
35. Please provide any additional comments:
Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit Submit and Print

* indicates a required field