O’Neal Outreach Materials & Speaker Request

Requesting organization/group(Required)

Name(Required)

First Last

Email(Required)

Phone(Required)

What is your preferred method of contact?(Required)

Phone

Request Type

Request Type(Required)

Do you also need educational materials for this event?(Required)

Event Details

Name of Event or Health Fair(Required)

Date event begins(Required)

Time event begins(Required)

Date event ends(Required)

Time event ends(Required)

Event check-in time(Required)

Location of the event/health fair(Required)

Physical Address(Required)

Street Address Address Line 2 City State ZIP Code

Specific population

Age range of participants

Bilingual requirements(Required)

Please check the equipment items below that will be provided by the requesting organization:(Required)

Table

Chairs

LCD Projector/Screen

Podium

Laptop Computer

TV & DVD/VCR

Event dress code

Educational Materials Request Details

Who is your target audience?(Required)

Please list the materials you are requesting(Required)

Mailing address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How many people do you expect to reach?(Required)

Are these materials being used at an event?(Required)

Other

Please describe your request

Approvals(Required)

I understand that if my request is not submitted four (4) weeks prior to my event, a volunteer/speaker may not be available to attend. Educational materials may be provided on a shorter notice if approved.