Community Event Request

Community Event Request Form

You are not required to identify yourself or submit any personal information. However, it will be helpful should we need to contact you for additional information.

Under Florida Law, e-mail addresses are public records. If you do not want your e-mail address released in response to a public records request, do not send electronic mail to this entity.

Agency / Business / Event:* - required

Requester's Name:* - required

Phone #:* - required

Email Address:* - required

Event Date:* - required

Start Time:

End Time:

Description / Details:* - required

Location and Address:

Location Set-Up: (indoors / outdoors, tables, etc)

Program / Service Line:

Health Care District - Outreach C.L. Brumback Clinic (Medical/Dental/Behavioral Health/Mobile Clinic) School Health Trauma Agency E.J. Healey Center Lakeside Medical Center

Services Requested:

Staff:

Clinical Non-Clinical Both maximum 1 allowed

Targeted Audience:

Demographics/(#attendees, age, etc.):

Sponsorship:

Upload Supplementary Information:

Refresh Get Audio Code

Type the code from the image

Mandatory field(s) marked with *