Event Date:

Agency or Community Partner:

Contact Person:

Contact Person's Email:

Contact Person's Phone:

Event Setup Time (if applicable):

Event Start Time:

Event End Time:

Expected # of Participants:

Event location and directions (please include address and cross streets):

Outreach or Speaking Request:

HIV Overview Presentation
Harm Reduction Presentation
Substance Abuse Presentation
Gender Identity & Human Sexuality Presentation
Living with HIV Presentation
HIV Treatment Presentation
Booth or Tabling for Social Service Agency
Booth or Tabling for High School Event
Booth or Tabling for University/College Event
Booth or Tabling for other community Event
Request for On-Site HIV Rapid Testing

Is there a dress code?

Yes
No

If Yes, please explain:

Condoms

Yes, Please bring condoms and you are able to do a condom demostration
Yes, please bring condoms but you are not allowed to do a condom demostration
No, you are not allowed to bring condoms

If No, please explain:

For Presentations-

There will be a chalk board, dry erase board, or other writing surface available
There WILL NOT be a writing surface available.
I am not requesting a Presentation

For Community Booths-

A table and chairs will be provided for the indoor event.
A table and chairs will be provided for the outdoor event.
A table, chairs, and tent will be provided for the outdoor event.
No table or chairs will be provided
I am not requesting a Community Booth

Are there any topics we cannot discuss?

Yes
No

If Yes, please explain:

Additional Notes or Comments:

What kind of brochures/pamplets should we bring? (Check all that apply)

HIV
STIs/STDs
Viral Hepatitis
Latino
en Espanol
African American
Heterosexual
Gay/Bi
Self Esteem
Older Adults
Youth
Sexual Health