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2. First Name*
3. Last Name*
5. Organization*
6. Phone Number*
8. Type of organization
9. E-mail*
11. Event Title
12. Date of Event*
    Date of Event
13. Set-Up Time
    Set-Up Time
15. Event Location
17. Event Start Time*
    Event Start Time
18. Event End Time*
    Event End Time
20. Brief Description of Your Event
22. What type of information or education would you like provided to attendees?

    1. Breast Health
    2. Women's Health
    3. Pediatric - Children's Health
    4. Oral Health
    5. STI/STD Education

    1. Nutrition and Physical Activity
    2. Substance Use
    3. Diabetes Education and Awareness
    4. Environmental Health

    1. Teen Pregnancy and Sexual Health
    2. Mental and Behavioral Health
    3. Tour CHA
    4. Intro to Public Health
24. Has CHA attended the event previously?

    1. Yes
    2. No
25. Bilingual staff needed?

    1. Yes
    2. No
27. What items will be available?

    1. Tables / Chairs
    2. Covered Area or Tent (outdoor events only)
    3. Water / Refreshments

    1. Free parking for CHA staff
    2. Computer or laptop
    3. Projector and screen
29. Estimated Number of Attendees:*
    If less than 20 people, CHA staff will contact event organizer.
30. Age Range of Attendees:
32. Participant / Audience Description:

    1. General Public
    2. Employees / Staff
    3. Students
    4. Other
34. Does your event require a cooking demonstration?

    1. Yes
    2. No

    Please visit: https://www.cabarrushealth.org/408/Group-ClassesSpecialty-Class and complete the Specialty Class Registration and Interest form.

36. Other

    Briefly describe the Participants / Audience for your event.

38. Cabarrus Health Alliance makes every effort to staff all requests for our participation in community events. Your request must be submitted a minimum of 30 days prior to event date. Once your request is received, we will respond within ten (10) business days.
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40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit

* indicates a required field