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Event or Presentation Request Form

All requests are required to be submitted at minimum 14 days in advance.

* Indicates required fields

Event Name *

Requester First Name*

Requester Last Name*

Organization Name*

Organization ZIP Code*

Phone(e.g. XXX-XXX-XXXX)*

Email *

Event Date*

Event Time*

Event Borough*

Event Address/Location *

Event ZIP/Postal Code*

Type of Request *

Expected Number of Attendees *

Target Audience (Older Adults 60+, Professionals, Caregivers, Agencies, etc.) *

Event Topic *

Describe the Event or Presentation Requested *

Will you need materials in other languages? *

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