Speaker and Health Fair Request Form

Please note that The Health Department will not attend or promote events that require any monetary payments.

         

Type of Request (Please check one): Speaker Request (lecture setting, non-health fair)
Health Topic	Please choose one:Alcohol and Drug Use PreventionFood LabelHigh Blood PressureMedication AdherenceNutritionPharmacists as Your Medication SpecialistPrevent and Control High CholesterolCommunicable DiseasesFlu/InfluenzaHIV/AIDSImmunizationLead Poisoning PreventionMental Health (Depression, Stress)Poison ControlSexually Transmitted DiseasesTobaccoTuberculosisWest Nile Virus
Health Fair (tabling)
Health Topic	All Health TopicsAlcoholAsthmaCancerCardiovascular Health (Hypertension)Communicable DiseasesDiabetesFlu: GeneralHIV/AIDSImmunizationLead Poisoning PreventionMental HealthNutritionPest ControlSexually Transmitted DiseasesTake Care New YorkTobaccoTuberculosisWest Nile Virus
Events Calendar only
Would you like to add your event into our Calendar?	Yes No
Title of Event*
Date of Event*
Set-up Time *
Start Time *
End Time*
Event Location*
Street Address *
City *
State *
Zip Code *
How many people are expected to attend? *
Target Group*	GeneralFamiliesMenWomenChildrenSeniorsGrade school studentsHigh school studentsCollege studentsMedical/health professionalsDelegates
Preferred Language(s)*	EnglishSpanishChinese
Host Organization(s) *
Contact Person *
Phone Number *
Cell Number
Email *
Date you need a response by *
Additional Notes (For example: materials provided for events such as chairs, tables, etc.)
If we cannot attend your health fair but you would like us to provide you with our health literature, please provide the address where our materials should be sent to.

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