Health Education Services- Community Request

Health Education Services- Community Request

Outreach Support Request form for community-based and civic organizations. Please complete thoroughly. The Community Health Education Team offers various opportunities to inform and educate community members on COVID Safety Basics, COVID Care, Vaccines, Guidelines, living well after the COVID pandemic, monkeypox, and chronic diseases.

Today's Date*

Type of Outreach Service Requested*

Select

Name of Event

Enter the name of the community event.

Date of the Event*

Time of the Event*

Expected Age Group*

Select

Event Location Address*

Enter the physical address of the event, or enter the virtual meeting link/URL address.

Location Environment*

Select

Expected Number of Attendees*

Enter the anticipated number of people in attendance.

Requesting Organization Name:*

Enter the name of the organization or business.

Contact Person Name:*

Enter the first and last name of point of contact.

Contact Person Phone Number:*

Enter the phone number of the point of contact.

Contact Person Email:*

Enter the email address of the point of contact.

Presentation/ Class Topics:*

Select

COVID Basics, Select One:

Select

Understanding the Guidelines, Select One:

Select

COVID Care, Select One:

Select

Health Literacy and Equity, Select One:

Select

Wellness Beyond COVID, Select One:

Select

Number of Materials Requested

Topic of Materials Requested*

Select or enter value

Navigation Support Topics:*

Select or enter value

Please add any other details to this request:

Delivery Address:*

Quantity*

Privacy Notice|Report Abuse

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.