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Outreach Event Request

• Outreach Event Request

OUTREACH EVENT REQUEST

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Business, Agency, Church, Event Name *

Contact Name *

First

Last

Who will be the contact person for the event?

Phone *

Email *

Email

Confirm Email

Event Location *

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Date and Time of Event *

Date

Time

Setup Time *

Services Request For Event (Choose all that apply) *

• Free HIV Testing
• Information Table
• MOL Services Presentation
• Free Condoms
• HIV/STI Education Information Class
• Bros In Convo
• Divas In Dialogue

Will there be a private room that can be used for testing (door that can be closed, preferably with no windows, or a way to cover windows completely) *

• No
• Yes

If no room, will there be a designated place for our mobile testing unit? *

• No
• Yes

Submit

Some items are ordered from manufacturer directly, and may take 4-6 weeks to arrive. Dismiss