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2. Montgomery County Department of Health and Human Services - Office of Community Information and Education
   Education Program/Health Fair Request Form
4. First Name
5. Last Name
7. Contact Information*
9. Please check one:

   1. Education Program
   2. Health Fair (Staff attending with a table display)

   1. Health Fair (Interactive with short presentation)
   2. Health Fair (Materials Only)
11. Organization/Event Title*
13. Address
15. City
16. State
17. Zip
19. Expected Program Date/Time

    1. 1-3 Months
    2. 3-6 Months
    3. 6-12 Months
    4. Undecided
21. If scheduled event, program date/time:
22. Date:
23. Time:
25. Program Topic (Please select all that apply)
27. Chronic Disease
    -- Select One --Heart Health EducationCDC Diabetes Prevention Program
28. Injury Prevention
    -- Select One --Car Seat ChecksCPR/AED Certification TrainingSuicide Prevention - QPR Training
29. Transportation Safety
    -- Select One --Aggressive DrivingBicycle SafetyDistracted DrivingHeavy Truck/Commercial Vehicle SafetyImpaired DrivingMature Driver SafetyMotorcycle SafetyPedestrian SafetySeatbelt Car Seat SafetyYoung Driver Safety
31. Nutrition
    -- Select One --General Nutrition Education (K-Adults)
32. Physical Activity
    -- Select One --Elmwood Park Zoo Program - Junior Inspector ProgramMontco Trail Challenge
34. If you would like to request multiple programs from the above drop-downs, please list below.
36. Grade/Age Range of Audience:

    1. Preschool (Age 4)
    2. Elementary (grade K-5)
    3. Middle School (grade 6-8)
    4. High School (grade 9-12)
    5. College

    1. Adult (age 19-55)
    2. Older Adults (age 55+)
    3. Professionals
    4. Mixed Audience
38. How many people do you expect at the program/health fair?
40. Montgomery County Office of Public Health participation is dependent on several factors including staff availability, material supply, and other program/grant requirements.
42. This project is funded by the Pa. Department of Health's Preventive Health and Health Services Block Grant.
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44. 1. Receive an email copy of this form.
45. Email address

    This field is not part of the form submission.

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