Health Fair Presentation Request

    AGENCY/ORGANIZATION NAME*
    CONTACT NAME*
    CONTACT EMAIL*
    CONTACT PHONE*


    ADDRESS of HEALTH FAIR/PRESENTATION

    STREET*
    CITY*
    STATE*
    ZIP*


    ON-SITE PERSON TO REPORT TO AT THE HEALTH FAIR*
    ON-SITE PERSON CONTACT PHONE*
    NUMBER OF ATTENDEES (ESTIMATE)*
    HEALTH FAIR PRESENTATION DATE
    HEALTH FAIR PRESENTATION TIME


    WILL THE FOLLOWING BE PROVIDED
    SCREENINGS REQUESTED?*