Booth/Health Fair Request

Thank you for your interests in having us come to your organization!

Today's Date

Event Date

First Name

Last Name

Phone Number

Email (Enter twice to verify)

Name of company/group requesting for booth/health fair

Street address/Location for booth/health fair

Audience

Adult (18+)

Adolescent (13-17)

Seniors (60+)

Children (12 and under)

Mental Health Professionals

Educators

Family & Friends

Individuals with Mental Disorder

If other, please specify

Expected number of attendees

Event time frame (start and end time)

Total number of booths/presenters expected

Equipment Available

Table

Chairs

Power Outlet

If chairs are provided, please indicate the amount

Cost associate with the event?

Yes

If "yes," how much?

Reason for request

Continuing Education

Employee Health Education

Community Resources

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