DCPH Engagement Request Form

Event Title or Focus

Agency Requesting Presentation/Collaboration*

Presentation/Health Fair/Event Date

Presentation/Health Fair/Event Time

Please include as much information about event time as available. This may include start time, stop time, and set-up.

Location/Address for Event

Zip Code*

Please enter numeric zip code where presentation/health fair/event will take place.

Primary Contact Name*

Primary Contact Email*

Primary Contact Phone

Preferred Method of Communication

Select or enter value

Presentation Subject*

Select or enter value

Anticipated Number of Attendees

Additional Information for DCPH Team

Please include all details that you believe would be helpful for our team to know about your event or request.

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