GVPH Program Request Form

GVPH Program Request Form

Granville Vance Public Health is happy to offer health education, training, and services to community groups and organizations. If you have a special program request, please provide information below so that we may assist you. Please submit your request at least a month (30 days) in advance to allow appropriate time for scheduling and planning for your event.

First Name*

Last Name*

E-Mail*

Phone Number*

Sponsoring Organization/Department*

Audience:*

Select or enter value

If other, please identify

Size of Audience*

1-25

26-50

51-100

101-200

200-300

300-500

500+

Location of Event*

Address of event*

Will tables and chairs be provided?*

Select or enter value

Indicate 1st choice of program Date*

Indicate 1st choice of program time*

Indicate 2nd choice of program date

Indicate 2nd choice of program time

Length of program*

Topic of Program (Please Describe):*

Program Objectives*

Please choose program format*

Classroom

Roundtable discussion

Tabling event

Other

If other, please describe:

Please share any additional requirements needed:

Send me a copy of my responses

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