Outreach Participation Request Form

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Outreach Participation Request Form



* Event Date:
* Event Name:
* Street:
* City / State / Zip:
* Event Time:
Start:  
    
End:  
* Event Contact Person:
Job Title:
* Email Address:
* Telephone:
* Languages Needed:
English
Spanish
Armenian
Cambodian
Chinese
Farsi
Korean
Russian
Tagalog
Vietnamese
* Number Expected to Attend:
* Specific Program Information Requested:
CalFresh
Medi-Cal
Supportive Services
Other Program(s): 
Oral Presentation Requested, if so, which programs?
Items Provided:
Table
Chair(s)
Canopy
Helium Tank
Other Items Provided: 
* Indoor / Outdoor event?
indoor
outdoor
* Set up and take down time:
Start:  
    
End:  
Assistance with Loading / Unloading?
Reserved Parking?
Refreshments and Water Provided?
Other Event Details:




* Required fields.

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