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2. Contact Information
4. Organization/Agency Name*
5. First Name*
6. Last Name*
8. Email Address*
9. Phone Number*
11. Event or Presentation Details
13. Event Name*
14. Event Space*

    1. Indoors
    2. Outdoors
16. Event Location Address*
17. Zip Code
18. City
20. Event Date*
    Event Date
21. Event Start Time*
    Event Start Time
22. Event End Time*
    Event End Time
24. Audience Type (i.e Age, Gender, Population)*
25. Number of Expected Attendees*
27. Service Requested*

    1. Information Table
    2. Presentation
    3. Handouts or Materials
    4. Other
28. Please provide a detailed description of your event and the services you are requesting from Duplin County Health Department (Health Education & Outreach Team). *
30. Choose Health Topics of Interest*

    1. Breast & Cervical Cancer Control Program (BCCCP)
    2. Breastfeeding
    3. Car Seat Safety
    4. Childhood Injury Prevention (Safe Kids)
    5. Chronic Disease Prevention (Diabetes, High Blood Pressure, Cholesterol, etc.)
    6. Disaster Preparedness (Hurricane)
    7. Environmental Health
    8. Family Planning
    9. Healthy Eating
    10. Immunizations

    1. Infectious Diseases (Flu, COVID, TB, etc.)
    2. Mental Health / Stress Management
    3. Personal Hygiene (Hand Washing, Dental, etc)
    4. Reproductive Health/ Pregnancy Prevention / Sexual Health
    5. STD/STI Awareness & Prevention
    6. Substance Use & Overdose Prevention
    7. Tobacco & Vaping Education & Prevention
    8. Women Infant and Children (WIC) Program
    9. Other
32. If Other Please Specify
33. Equipment Provided by Event Organizer*

    1. Computer/Laptop
    2. Dry Erase Board
    3. Microphone
    4. Projector
    5. Table and Chairs
    6. Tent/Shaded Area
    7. Wireless Internet
35. Additional Information
36. Please attach your event flyer or any advertising materials here if available
38. Outreach Site Selection Policy
    1. • Event requests must be made at least 3 weeks in advance.
       • Services offered will be mutually agreed upon and confirmed prior to the event.
       • Services offered may vary depending on the event and availability of equipment and supplies.
       • Public Health participation is dependent on the availability of Public Health staff.

       Please note: submission of this form does not constitute a confirmation of Public Health's participation in your event. A Public Health staff member will contact you to discuss your event or presentation request, and the availability of staff for your event.

40. Today's Date*
    Today's Date
41. First & Last Name*
Leave This Blank:


43. 1. Receive an email copy of this form.
44. Email address

    This field is not part of the form submission.

45. Submit

* indicates a required field