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Health/Resource Fair Request Form

 

Only requests from individuals or organizations in our service area can be considered. The North Carolina Triangle to the Coast Affiliate service area covers 29 counties including: Bladen, Brunswick, Caswell, Chatham, Columbus, Duplin, Durham, Edgecombe, Franklin, Granville, Halifax, Harnett, Johnston, Lee, Moore, Nash, New Hanover, Northampton, Onslow, Orange, Pender, Person, Pitt, Sampson, Scotland, Vance, Warren, Wake, and Wilson.

Requests must be received at least four weeks prior to event date. A speaker or representative is NOT guaranteed for your event. Requests are filled on a first come, first serve basis and are subject to staff and volunteer availability. Should a representative not be available, educational materials can be purchased or printed from our website.

Please note that while Breast Cancer Awareness Month (October) and Race for the Cure months (September & May) are very popular times to host events, our limited staff and volunteer core will be heavily committed during these times and may not be able to provide the same level of assistance as other times of the year.

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2. Contact Person Information and Location of the Event

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Name:

 

 

   

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City/State/ZIP:

 

    

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*3. Location of Event
(Select one of the available choices or enter a different value.)



*4.
Question - Required - Date of Event




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*9.
Question - Required - Audience
Please make between 1 and 8 selections from the choices below.

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   Please leave this field empty