PLEASE NOTE: Requests must be received a minimum of 6 weeks in advance of the event to be considered. Participation by SCPH is based on staff availability
Agency Requesting Information: *
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PRIMARY CONTACT:
Primary Contact First Name: *
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Last name: *
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Primary Contact Email Address: *
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Primary Contact Phone Number: *
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Primary Contact Fax Number:
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ALTERNATE CONTACT:
Alternate Contact First Name:
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Alternate Contact Last Name:
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Alternate Contact Email Address:
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Alternate Contact Phone Number:
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EVENT:
Name of Event: *
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Location of Event: *
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Address of Event *
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Date of Event *
MM
/
DD
/
YYYY
Start Time of Event *
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End Time of Event *
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Purpose of Event / Applicable SCPH Service Area: *
Please select all that apply.
Required
Audience for Event:
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Anticipated Number of Participants: *
Has SCPH participated in this event in the past?
What type of participation are you requesting from us? *
Please select all that apply
Required
What type of resources/information are you requesting?
Please select all that apply.
What quantity of materials are you requesting?
Is there a fee for participation? *
Will there be access to tables? *
Please provide any additional information that may be helpful to us:
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How did you hear about Summit County Public Health for your event?
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