Rowan County Health Department (RCHD)
Community Outreach and Education Request
(Please request services at least two (2) weeks in advance of your event)
Name of Event:
Organization Hosting Event:
Contact Person(s):
Telephone #: E-mail:
Event Location/Address:
Event Date: Event Time:
Service Being Requested:
Topic/Subject to be Presented:
Format:
Booth Class (Interactive) Educational Literature Only (no RCHD staff present)
Presentation (Lecture) Other Request:
Participant Information (check all that apply)
Estimated Number of Participants:
Demographics:
Child Teen Adult
Senior (60+)
Language
English Only English and Other:
Other Language
Literacy (Reading) Level:
Elementary/Junior High High School College
Tables Chairs
Access to outlet
Additional Information:
Available at Your Facility/Location (check all that apply):
Projector Screen Computer
Mail: Rowan County Health Department
ATTN: Health Education
1811 East Innes Street.
Salisbury, NC 28146
Fax: 704-216-7968
Email: Alyssa.Harris@rowancountync.gov
You may also mail, fax, or e-mail this completed form:
Form updated: 07/08/2020
