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Event Request Form

Community Event Request Form

"*" indicates required fields

Thank you for your interest in partnering with the Charles County Department of Health for your upcoming event. To request that the Department participate in your event or provide materials, please complete the event request form at least two weeks prior to the event. All requests are reviewed once received. Our ability to honor your request is based on staffing and date. The form is a notification to the Public Affairs Specialist and not a confirmation that the Department will participate. Depending on those items, we may be able to provide staff and materials or just materials. If we only are able to provide materials, you may have to coordinate a pick-up date and time with us. If you have any questions or cannot fill out the online form, call 301-609-6759. ** We are not able to offer any type of screening (blood pressure, cholesterol, etc.).
Name*
MM slash DD slash YYYY
Preferred Contact Method*

Sponsoring Organization

Event Address
Event Set-Up Time
:
Event Begin Time
:
Event End Time
:
The event will be held
(check all that apply)
MM slash DD slash YYYY
Will tables and chairs be supplied?
Is it free to participate?

Program Interests:

Behavioral Health
Check all that apply
Community Health
Check all that apply
Environmental Health
Check all that apply
Infant, Children and Adolescent Services
Check all that apply
Uninsured or Low-Cost Health Care
Check all that apply