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Outreach Interest Form

Event Information

Event Title

Event Date

Start Time

End Time

Vendor Setup Time

Rain Date

Venue Address

City

State

Zip Code

Your Information

Your Name *

Your Name

First

Last

Email

Bureau

Program *

Your Supervisor's Name *

Your Supervisor's Email *

Administration

Programs Attending

Central Services

Communications

Finance

HERJ

Human resources

Information Technology

Office of Assessment and Planning

Emergency Preparedness

Student Volunteer

HERJ Health Ambassadors

Name of organization:

Organizations POC: (Point of Contact)

First

Last

POC Email

POC Phone

How many team members attending?

Behavioral Health

Programs Attending

Adolescent and Family Services

Road to Recovery Clinics

Recovery Community Support Services

System Planning and Management

System Training Education and Prevention Services

Disease Prevention and Management

Programs Attending

Chronic Disease Prevention

HIV/STI Prevention and Care

Infectious Disease Prevention and Control

Immunizations Program

Public Health Emerging Pathogens Response

Environmental Health

Programs Attending

Food Protection Services

Housing Protection Program

Sanitary Engineering

Family Health

Programs Attending

Access to Care

Adult Evaluation and Review Services (AERS)

Dental Health

MA Transportation

Maternal and Child Health

WIC

School Health and Support

Programs Attending

Audiology

Clinical Services

Operations

Program Representative

Name of representative/s:

First

Last

Representative/s email address:

Add a Representative Remove a Representative

Materials

What materials will you provide?

Giveaways

Flyers/Brochures

Health Screening/Testing

Training/Seminar

N/A

OtherOther