Community Event Request Form
Thank you for your interest in partnering with the Charles County Department of Health for your upcoming event. To request that the Department participate in your event or provide materials, please complete the event request form at least two weeks prior to the event.

All requests are reviewed once received. Our ability to honor your request is based on staffing and date. The form is a notification to the Public Affairs Specialist and not a confirmation that the Department will participate. Depending on those items, we may be able to provide staff and materials or just materials. If we only are able to provide materials, you may have to coordinate a pick-up date and time with us.

If you have any questions or cannot fill out the online form, call 301-609-6759.

** We are not able to offer any type of screening (blood pressure, cholesterol, etc.).
First Name *
Your answer
Last Name *
Your answer
Event Date: *
MM
/
DD
/
YYYY
Phone number *
Your answer
E-mail
Your answer
Preferred contact method *
Required
Sponsoring Organization:
Organization Sponsoring Event: *
Your answer
Event Name: *
Your answer
Brief Description of the Event
Your answer
Event Location:
Your answer
Street Address:
Your answer
City:
Your answer
Zip Code:
Your answer
Event Set-up Time:
Time
:
Event Begin Time:
Time
:
Event End Time:
Time
:
How many years have you held this event?
Your answer
Number of Attendees Expected?
Your answer
Audience Description
Your answer
The event will be held (check all that apply):
Rain Date:
MM
/
DD
/
YYYY
Will Tables and Chairs be Supplied?
Is it Free to Participate?
If event is not free, what is the cost to participate?
Your answer
Is there anything else we should know about the event?
Your answer
Program Interests:
Behavioral Health (check all that apply):
Community Health (check all that apply):
Environmental Health (Check all that apply):
Infant, Children and Adolescent Services (Check all that apply):
Uninsured or Low-Cost Health Care (Check all that apply):
Is there any other information you would like us to know?
Your answer
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