Presentation and Health Fair Request Form ZIKA
What are you requesting? Presentation or Health Fair
Please Enter Today’s Date
RadDatePicker
Open the calendar popup.
Please enter HCPH Employee Contact Name. (if applicable)

INFORMATION ON REQUESTING GROUP

Please Enter Organization Name
Please Enter the name of the Contact Person
Please enter your address. STREET NAME CITY STATE ZIP CODE
Please enter your Phone number
Please enter your email address
Please Select Yes or No
When have we presented to them before?

EVENT INFO

Please enter start Date and time of the Event
RadDatePicker
Open the calendar popup.
  Time:
Please enter end date and time of the event
RadDatePicker
Open the calendar popup.
  Time:
Address of Event (if different than above) STREET NAME and NUMBER CITY STATE ZIP CODE
Please describe Theme (if any)
Expected # of Attendees
Please Select Language Needed
Please enter other languages
Media Invited?
Please select the Target Audience from the list





Please type Target Audience if not available above.
Please enter your comments

LOGISTICS

Please choose location, INDOOR or OUTDOOR or both
Please select yes or no for Electricity
Projector Provided (if applicable)
Table/Chairs Provided (if applicable)
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Enter the code shown above in the box below.