Health and Wellness Event Request Form

• About You

• Last Name
• First name
• Email
• Phone

  Phone - ### - ### ####

• About Your Organization

• Group Name
• Street Address
• City
• Zip Code

• About the Event

• Name of Event
• Date of Event

  Date of Event / MM / DD YYYY

  
• Start Time

  Start Time : HH MM AM PM AM/PM
• End Time

  End Time : HH MM AM PM AM/PM
• Where is the Event?
  Where is the Event?

  Indoor Outdoor Both
• Expected Number of Attendees
• Event Street Address
• City
• Zip Code
• Expected Audience (Please check all that apply)
  Expected Audience (Please check all that apply)

  General Community Members Homeless Incarcerated LGBTQ Men Women Veterans Other Other
• Age Range of Audience
  Age Range of Audience

  Infant/Toddler Children Teens 13-18 yrs Young Adults 18-25 yrs Adults 25-55 yrs Seniors 55+ yrs
• Services Requested
  Services Requested

  Infant safe sleep/infant mortality Nutrition & physical activity for youth Sexual health services, prevention, information or testing Community Resources Immunization Information Tobacco Use and Prevention Breastfeeding Women, Infants & Children (WIC) Safe Communities/Traffic Safety Environmental Health- general services Green Spaces (parks & trails guide) Rabies/Mosquito Control (incl Zika/West Nile) Plumbing Information Private Water/ Private Sewage System Food Safety Inspections Food Safety Training Swimming Pools/Spas Other Inspections (Jails, Schools, Residential Camps, etc.) Radon Information Infectious Disease Information
• If requesting sexually transmitted infection testing and/or information, can condoms be distributed?
  Yes No
• Greene County Public Health can provide information only (no staff) for various health topics. If you are interested in having information only at your event, please let us know and we'll be in touch with what we have available at the time of your event.
• Additional Comments: