Outreach Event Request

* denotes required fields.

Organizer Name and Contact Information

Last name

Name *

Title *

Organization *

Email address *

Phone number *

Event name *

Event date *

Start time *

End time *

Event address/location *

Event information

Expected Audience Numbers

Youth/students (ages 0—21) *

Adults *

Target population(s) (check all that apply) *

Low-income

Minorities

Children

Lives in rural areas

English as a Second Language (ESL)

Refugees/immigrants

Disabled

Senior citizens

Women

Please describe the communities/neighborhoods the event will target (i.e., schools, churches, housing, youth groups, etc.)

Please specify any/all language(s)

Spanish

French

Other

Requested CUPHD resources (check all that apply) *

Swag

Flyers

WIC/nutrition

Sexual health/family planning

Lactation Station

Other

Will tables and chairs be provided? *

Yes No

Will the media be present at the event (TV, radio, newspaper, etc.)?

Yes No

If yes, please specify who

Organizer’s plans for marketing/promoting the event (please check all that apply)

Traditional media

Organization website

TV

Radio

Newspaper

Social media

Facebook

Instagram

YouTube

TikTok

Other social media

NOTE TO ORGANIZER: Please attach any event promotional materials to this form by clicking the button to the left. You may attach up to 5 photos with a maximum size of 5MB per file (PDF, JPG, PNG).

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