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The Cleveland department of Public Health (CDPH) is excited for the opportunity to work with your organization. Please complete the following form/fields with as much detail as possible. A staff member will follow-up within three business days.

All questions with an asterisk (*) are required.

Contact Person:

First Name: *

Last Name: *

Title:

Phone Number: (only area code and number) *

E-Mail: *

Event Information:

Company/Organization Sponsoring the Event: *

Address (numeric only): *

Street Direction: --Choose an Option-- N E W S

Street Name: *

Street Type: --Choose an Option-- Ally Arc Ave Blvd Bypa Cct Cl Crn Ct Cres Cds Dr Esp Grn Gr Hwy Jnc Lane Link Mews Pde Pl Rdge Rd Sq St Tce Plz *

City: *

State:

Zip Code: *

Event Address & Information:

Event Name: *

Event Address (numeric only): *

Event Street Direction: --Choose an Option-- N E W S

Event Street Name: *

Event Street Type: --Choose an Option-- Ally Arc Ave Blvd Bypa Cct Cl Crn Ct Cres Cds Dr Esp Grn Gr Hwy Jnc Lane Link Mews Pde Pl Rdge Rd Sq St Tce Plz *

Event City: *

Event State:

Event Zip Code: *

Set both dates with same date for one day events:

Event Start Date: *

Event End Date: *

Event Start Time: *

Event End Time: *

Description of Event (include population and neighborhood/ward to be served) *

Type of Participation:

Provide Educational Materials/Resources Table/Booth Blood Pressure Screenings STI (urine based) Screenings Pregnancy Test Family Planning Consultations Immunizations Presentation/Speaker Mobile Unit

Other Description:

Cost for Participation?: --Choose Option-- Yes No "); *

Describe Associated Cost:

Receive Future E-Mail Communication From CDPH

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