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Community Event & Education Request Form (H-9)

The City of Milwaukee Health Department is committed to community outreach and education. Each request or event attendance is evaluated on a case-by-case basis. Requests should be made at least 30 days in advance. Requests within a shorter timeframe will be accommodated if possible. Please note: You may be contacted by a designated City of Milwaukee Health Department staff member for further information.

*Required Fields

*Type of request

 Brochures/Program Materials Only  Table/Booth (ex. Health Fair)
 Presentation/Speaker  Testing/Direct Service
 Other: 

Organization


*Name of Organization:

*Contact Person: 

Address: 

*Phone:   

*Email:

*Type of Organization: 
   Government  Faith-based Organization
   Non-profit  School
   Business Healthcare Organization
  Media  
   Other:  

Event Details


*Date(s):                         

*Time (start and end time):   

*Location:

*Purpose of event: 

 

*Please select up to 5 topics for representation:
  Communicable Disease Men's Health
  Domestic Violence Prevention Newborn Screening
  Emergency Preparedness Public Health Lab
  Food Safety Safe Sleep
  Health Insurance Access & Public Benefits Sexually Transmitted Diseases (including HIV)
  Environmental Health (e.g. rabies, mold) Tattoo & Body Piercing
  Home Visiting Teen Pregnancy Prevention
  Immunizations WIC (Women, Infants & Children) Program
  Lead Poisoning Prevention Women's Health (Breast & Cervical Cancer)
  Lead & Water Other: 

 


*Is media invited to the event?

Yes    No    Unsure


Additional Event Information

Attendees:          
  Number expected: 0-50 50-100 100-200 200-500 500+
  Age ranges (check all that apply):  K-5th grade 6th-12th grade Adults
  Languages (check all that apply): English Spanish Other: 
Additional information about event target population:
What other community partners are involved?
Special instructions for vendor set-up (including set-up time and provided materials): 
 
What amenities will be provided by the event organizers? (check all that apply)
  Wireless internet Tent Tables/Chairs Meals Drinks Other: 
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