Community Event Request Form
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1DUTCHESS COUNTY DEPARTMENT OF
COMMUNITY EVENT REQUEST
BEHAVIORAL & COMMUNITY HEALTH
Health Planning & Education
85 Civic Center Plaza – Suite 106, Poughkeepsie, NY 12601
Tel: (845) 486-3421
Fax: (845) 486-3561
_________________________________________________________________________________________________________________________
Date of Request: ______________________
Event Name:__________________________________ Type of Event: _________________________________________
Date of Event: _________________________ Time of Event: ________________ RSVP BY: ___________________
Set up time: __________________________ Tear down time: ___________________________________________
Location of Event / Address: _________________________________________________________________________
Is the event: __Inside?
__Outside?
Event includes the provision of: ___Tents ___ Tables ___Chairs ___Electricity ___Lighting ___ Wi‐Fi Internet
Expected Attendance: _______________________________________________________________________________
Target Audience (Age, Ethnicity, etc): ___________________________________________________________________
Description of Event’s goal/purpose:___________________________________________________________________
==================================================================================================
Organization in charge of the Event: ____________________________________________________________________
Contact Person: ____________________________________________________________________________________
Contact Telephone: _________________________________ Contact Cell Phone: _______________________________
Contact email: _____________________________________________________________________________________
Backup Contact for Day of Event: Name:______________________________ Cell Phone:________________________
==================================================================================================
Requesting participation in:
Screenings (no more than 2):
__HIV/AIDS
__ Blood Pressure
__ Cholesterol
__ Flu Shots
__Glucose
__ Other:__________________________________________________
Education:
__ STDs
__ Lyme/Arthropod Disease __ Safe Food Handling
__ Substance Abuse
__ HIV/AIDS
__ Heart Disease
__ Traumatic Brain Injury
__ Sickle Cell
__ Diabetes
__ Car Seat Safety
__ Teen Pregnancy/Prevention
__ Lactation
__ Physical Activity
__ Drowning Prevention
__ Hypertension/High Blood Pressure
Other (specify) ___________________________________________________________________________________
==================================================================================================
Department’s approval: Yes / No
Assigned to Staff/Division : ________________________/_________________
Comments: ________________________________________________________________________________________
Signature of Commissioner or Designee: ____________________________
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