Health Department

Community Event Request

Please read the instructions prior to completing the Community Event Request screen.

Contact Information
Name  

Organization

Address

Phone    

Email    

Request Date
Event Information
Event Date and Time  

Event Type

Event Name

Event Location  


Number People Expected  

Description of Target Population  

Please make selections from each of the following lists. First, please indicate the subjects for which you want information. Then, select the type of service that you are requesting from the health department. If you are requesting Pamphlets/Materials, please select them from the list provided.

On what subjects are you requesting information?

Other (please be specific):
I request that the Health Department provide the following:

Other (please be specific):
I request the following Pamphlets / Materials: