COMMUNITY EVENT PARTICIPATION REQUEST FORM

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Adolescent Health COMMUNITY EVENT PARTICIPATION REQUEST FORM Working Together for a Healthier Richmond
	Organization Name:
	Address:
	Contact Person:		Phone:
	Your Email Address:
	Date of Event:		Start:	AM PM	End AM PM
	Location of Event (complete address)
	Description of Activities	Health Fair Community Event Faith Event Presentation Other (please explain)
	Number of People Expected to Attend:		Under 12
			12-14
			15-17
			18-25
			Over 25
	Name Any Other Agencies Participating:
	Purpose of the Event
	Specific services (with times) requested of Richmond City Health District- Adolescent Health
	Indoor event	Outdoor event
	Is there a cost for participating?		Yes No
	If yes, what is the cost?

Last Updated: 08-23-2011

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Adolescent Health COMMUNITY EVENT PARTICIPATION REQUEST FORM Working Together for a Healthier Richmond