Outreach Event Request Business, Agency, Church, Event Name:(Required) Contact Name:(Required)Who will be the contact person for the event? First Last Phone(Required)Email(Required) Enter Email Confirm Email Event Location/Venue Name:(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Event Date:(Required) Month Day Year Event Start Time:(Required) Hours : Minutes AM PM AM/PM Setup Time:(Required) Hours : Minutes AM PM AM/PM Service Request For Event:(Required)(Choose all that apply) Free HIV Testing Information Table Free Condoms HIV/STI Education Information Class Education – health topics Δ
