Note: submission of the request is not a confirmation.

Name of your event:

Address and name of building where your event will be held:

Date of event:

Expected attendance (#):

Event start time and end time:

Contact name:

Phone number:

Email (required):

Target audience (example: students, teachers, adults, families, employees, etc.):

If school, will kids come with teacher for: Set amount of timeJust "fly by"

Goals/theme of fair:

Topic(s)/display(s) requested:

Topics of presentation: NutritionHygieneDiabetesTobacco

How is the fair being promoted?

Will it be indoors? yesno

If not, will there be a tent provided? yesno

Will there be tables and chairs set up? (displays need a 6’ long table each): yesno

Other set-up instructions:

We would like to partner throughout the year, can we schedule one of the items below? yesno

Check all that apply: Speaker on health topic for employee lunch ‘n learn or support groupConsultation on food available to target audience (vending areas, cafeterias, mtgs)Can we join your health team meetings?