DOH-Collier County Outreach Request Form

MEDIA INQUIRIES

As part of our mission to protect, promote, and improve the health of all people in Florida through integrated state, county, and community efforts the Florida Department of Health in Collier County (DOH-Collier) participates in community events and presents health education classes to all audiences.

Please use this form to request DOH-Collier programs and return it to the DOH-Collier outreach coordinator with as much notice as possible. We will respond to your request promptly.

Under Florida law, e-mail addresses are public records. If you do not want your e-mail address released in response to a public records request, do not send electronic mail to this entity. Instead contact these offices by phone or in writing.

Name of Event or Organization:*

Event Date:*

Event Location:*

Indoors

Outdoors

Address:

Setup Time:

Event Begins:

Event Ends:

Brief Description/Theme or Health Education Topic Requested:

Expected Audience: (ex. children, parents, older adults, at-risk population, men/women, general)

Number of Expected Attendees:*

Contact Person: Name - Phone Number - Email

Additional Information: (ex. Accommodations such as tables, chairs, etc.)

Signature of requester:*

Date:

Enter Confirmation Number