Outreach Request

2. Contact Information
4. Organization / Agency*
5. Contact First Name*
6. Contact Last Name*
8. Email Address*
9. Phone Number
13. Audience Information
15. Gender(s) of Audience Members*
16. Audience Age Range*
17. Number of Expected Attendees*
21. Service Requested
23. Please select the service being requested.*

    See descriptions regarding accommodations needed for services to be considered.

    1. Vaccines (Flu or COVID-19)
    2. STD/HIV Testing
    3. Information Table
    4. Presentation
    5. Other
25. Please provide a detailed description of your event and the services you are requesting from New Hanover County Health Public Health. *

    Please also include the names of any additional agencies you will be inviting to your event. This information will assist Public Health staff in planning and preparing for your event.

29. Event or Presentation Information
31. Event Name*
32. Event Location Address*
33. Event Space*

    1. Indoors
    2. Outdoors
35. Preferred Event Date*
    Preferred Event Date
36. Alternate Event Date (if applicable)
    Alternate Event Date (if applicable)
37. Event Start Time*
    Event Start Time
38. Event End Time*
    Event End Time
42. Topics of Interest
44. If requesting an information table or presentation, please select up to 3 topics of interest*

    1. Breast and Cervical Cancer Control Program (BCCCP)
    2. Breastfeeding
    3. Car Seat Safety
    4. Childhood Injury Prevention (Safe Kids)
    5. Chronic Disease Prevention
    6. COVID-19
    7. Environmental Health
    8. Family Planning
    9. Fitness / Physical Activity
    10. Healthy Opportunities Program (HOP)
    11. Hurricane Disaster Preparedness
    12. Immunizations

    1. Mental Health / Stress Management
    2. Nutrition
    3. Oral Health
    4. Personal Hygiene
    5. Puberty
    6. Reproductive Health / Pregnancy Prevention / Sexual Health
    7. STDs / HIV Awareness
    8. Substance Misuse Prevention
    9. Tobacco Prevention and Control
    10. Vaping / E-cigarette
    11. Women Infant and Children (WIC) Program
    12. Other
46. If you selected "Other" in the question above, please describe your health topic of interest here
50. Equipment to be Provided by Event Organizer
52. Please select the equipment you will provide for Public Health staff at the event location*

    1. Computer
    2. Dry Erase Board
    3. HDMI Connection
    4. Microphone
    5. Projector
    6. Table and Chairs
    7. Tent
    8. Wireless Internet
    9. None
    10. Other
56. Advertising Information
58. Advertising Method(s) - Please select all that apply*

    1. Billboards
    2. Flyers / Posters
    3. Magazine / Newspaper
    4. Radio Advertisement
    5. Social Media
    6. Television
    7. Word of Mouth
    8. Other
59. If available, please attach your event flyer or any advertising materials here
    • Accepted file types: jpg, gif, png, pdf, doc, docx, ppt
    • Maximum file size: 2 MB
    • A maximum of 5 files may be uploaded.
63. Additional Information
65. Is there anything else you would like us to know about your event?
69. Outreach Site Selection Policy
    • Event requests must be made in writing at least one month in advance.
    • Services offered will be mutually agreed upon and confirmed prior to the event.
    • Services offered may vary depending on the event and availability of equipment and supplies.
    • Public Health participation is dependent on the availability of Public Health staff.

    Please note: submission of this form does not constitute a confirmation of Public Health's participation in your event. A Public Health staff member will contact you to discuss your event or presentation request, and the availability of staff for your event.

71. I have read the Outreach Site Selection policy listed above.*

    1. I agree
72. Your Name*

    First

73. Last

75. Today's Date*
    Today's Date
Leave This Blank:


77. 1. Receive an email copy of this form.
78. Email address

    This field is not part of the form submission.

79. Submit

* indicates a required field