Community Outreach Request

It takes time to identify the appropriate resources and staffing needs for each opportunity. Please follow the guidelines within this form to be sure your event request is considered. Late or incomplete requests may cause additional delays. If your request involves manpower, immunizations or screenings, it must be received at least 90 days prior to the event to schedule staff, obtain licenses, and arrange materials. All other requests for event support must be submitted at least 60 days prior to your event. Printed materials (if available) can be fulfilled within 30 days. If you wish to have your event considered, please fill out this form.
YesNo
Name of Requesting Organization:*
We are only able to support events and programs held within Frederick County. Requests outside this area are not eligible.
Address of Organization:*

Street Address

Street Address Line 2

CityState

Zip Code
Official Website:*
www.example.com
Primary Contact Name:*

First NameLast Name
Primary Contact Email Address:*
example@example.com
Primary Contact Phone Number:*
###-###-####Format: (000) 000-0000.
What is the primary purpose of your organization:*
EVENT/PROGRAM DETAILS
Event/Program Name:*
Date/Start Time of Event:*

MonthDayYear
Hour MinutesAM/PM Option
End Time of Event:*

Hour Minutes

AM/PM Option
Location of Event:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Expected Number of Attendees:*
example: 23
Please describe the type of health-related activities that will be conducted at the event:*
Please describe the participants that will attend the event:*
SpeakerMedical ScreeningPamphlets & Speaking MaterialsDemonstrationsFinancial support to purchase health-related tools or materials for eventSponsorshipCOVID-19 VaccineOther
IndoorsOutdoors
Event setup time?*
Event tear down time?*
Is parking available for vendors? If so, please specify.*
Are there any vendor restrictions?*
Please submit any other important information we may need to know about your request or event:
Should be Empty:

EVENT/PROGRAM DETAILS