Outreach Event Request
Champaign Urbana Public Health District
For questions, email
Karen Gehrt
or call
217-531-5356
.
*
denotes required fields.
Organizer Name and Contact Information
Last name
Name
*
Title
*
Organization
*
Email address
*
Phone number
*
Event name
*
Event date
*
Start time
*
↓ Select time
9:00 am
9:30 am
10:00 am
10:30 am
11:00 am
11:30 am
12:00 pm
12:30 pm
1:00 pm
1:30 pm
2:00 pm
2:30 pm
3:00 pm
3:30 pm
4:00 pm
4:30 pm
5:00 pm
5:30 pm
6:00 pm
6:30 pm
7:00 pm
7:30 pm
8:00 pm
End time
*
↓ Select time
9:00 am
9:30 am
10:00 am
10:30 am
11:00 am
11:30 am
12:00 pm
12:30 pm
1:00 pm
1:30 pm
2:00 pm
2:30 pm
3:00 pm
3:30 pm
4:00 pm
4:30 pm
5:00 pm
5:30 pm
6:00 pm
6:30 pm
7:00 pm
7:30 pm
8:00 pm
Event address/location
*
Event information
Expected Audience Numbers
Youth/students (ages 0—21)
*
Adults
*
Target population(s) (check all that apply)
*
Low-income
Minorities
Children
Lives in rural areas
English as a Second Language (ESL)
Refugees/immigrants
Disabled
Senior citizens
Women
Please describe the communities/neighborhoods the event will target (i.e., schools, churches, housing, youth groups, etc.)
Please specify any/all language(s)
Spanish
French
Other
Requested CUPHD resources (check all that apply)
*
Swag
Flyers
WIC/nutrition
Sexual health/family planning
Lactation Station
Other
Will tables and chairs be provided?
*
Yes
No
Will the media be present at the event (TV, radio, newspaper, etc.)?
Yes
No
If yes, please specify who
Organizer’s plans for marketing/promoting the event (please check all that apply)
Traditional media
Organization website
TV
Radio
Newspaper
Social media
Facebook
Instagram
YouTube
TikTok
Other social media
NOTE TO ORGANIZER: Please attach any event promotional materials to this form by clicking the button to the left.
You may attach up to 5 photos with a maximum size of 5MB per file (PDF, JPG, PNG).
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