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Home > Programs and Services by Bureau > Community Initiatives > Civic Engagement and Advocacy > Outreach Program > Outreach Request Form

Boston Public Health Commission Community Outreach Participation Form

Requesting Agency
Agency Name * Contact Person *  
 
Contact Phone * Fax Email Address *
Day of Event Contact Day of Event Contact Phone
Event Information
Event Name * Event Theme


Event Location * Event Location Address *


Event Start Date and Time * Event End Date and Time *
 
 
Primary Language(s) of Target Audience Expected Attendance *


Neighborhood(s) to be Served * Target Audience
 
Materials/Services to be provided by the Boston Public Health Commission
What would you like BPHC to provide at your event? *
If Health Presentation, specify topic
(see topics below) 		Time Allotted for Presenter Start Time
Health Topics for Literarure Pick-Up, Resource Table and/or BPHC Health Presentation *
Event Logistics
Publicity Used for Event Event Setting
 
 
 
Is there parking for this event?
Is there a fee to park?  
Is there a fee to participate in this event? * If yes, specify cost:
Will tables and chair's be provided at the event ? * No. of Tables:
Chairs:
Will refreshments be served for staff/volunteers?
Comments/Questions

IMPORTANT
  • Please submit your request at the minimum 3 weeks prior to your event.
  • Requests will be honored based on capacity and availability of staff and resources.
  • Confirmation will be sent to event contact within 3 business days of receipt of request.
Contact Michaela Byrnes at (617) 534-2340 for questions.
Si tiene preguntas, pongase en contacto con Maria Ortega al (617) 534-2322