Event Request Community Health Fair/Event Request Contact InformationOrganization Name(Required)Organization Website(Required) Organization Description(Required)Contact Name (day of event)(Required) First Last Cell Phone (day of event)(Required)Event InformationEvent Name(Required)Event Description(Required)Event Location(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Confirmation Needed By (date and time)(Required)By what date and time do we need to confirm that we will be participating in this event? MM slash DD slash YYYY (Required) Hours : Minutes AM PM AM/PM Date of Event(Required) MM slash DD slash YYYY Set Up Time(Required) Hours : Minutes AM PM AM/PM Start Time(Required) Hours : Minutes AM PM AM/PM End Time(Required) Hours : Minutes AM PM AM/PM Additional InformationDo you charge admission?(Required) Yes No Is the event indoor or outdoor(Required) Indoor Outdoor Both Do we need to provide our own tent?(Required) Yes No Will you provide needed table and chairs?(Required) Yes No Will there be wi-fi?(Required) Yes No Will there be media covering the event?(Required) Yes No Please specify(Required)Will elected officials be invited?(Required) Yes No Please list(Required)Anticipated attendance(Required)Number of peopleEstimated age of attendees(Required)Check all that apply 0-2 3-6 7-17 18-24 25-34 35-44 45-64 65+ What is the goal of this event?(Required)Special instructions, requests or additional comments Δ
