Health Education Event Request Form

Health Education Event Request Form

Thank you for your interest in our COVID-19 health education services.

Please complete the request form below and a representative from the San Bernardino County Department of Public Health will reach out to gather more information.

Completion of this form does not guarantee or confirm the services requested.

Organization Information

Organization Type*

Select

Name of Organization*

Event Details

Event Name*

If this request is not for a particular event that your organization is hosting, please enter N/A.

Street Address*

City/Town/Unincorporated Area*

Select or enter value

Zip Code*

Type of Service Requested*

COVID-19 Health Education Tabling Event

COVID-19 Health Education Presentation

Handwashing Presentation

Potential Date of Event*

Please select a potential date for this event.

Please be aware that this date will remain tentative until a San Bernardino County Department of Public Health representative speaks with the event's point of contact to coordinate and confirm the service.

Potential Time of Event*

Potential Event Size*

Is the requested COVID-19 health education service for a private or public event?*

Private event

Public event

Space *

Select or enter value

Health Places Index (HPI)

It's okay if this is unknown but if you'd like to know more, please go to https://www.healthyplacesindex.org/. You can find the HPI score through utilizing the map and zip code.

Contact Information

Point of Contact's Name*

Point of Contact's Email*

Point of Contact's Phone Number*

Phone

How did you hear about us?

Event

Flyer

Website

Program Staff

Program Staff Name

Additional Event Information

Please let us know if there is anything else we should know, or if you would like us to connect you to other County services.

Send me a copy of my responses

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