MARC Healthy Environment event request form

We receive many requests for presentations and participation in regional events and activities. To help us determine your needs, please fill out the information below, and we will follow up with you.

Requests must be received a minimum of two weeks in advance to allow for proper scheduling. Regardless of lead time, we cannot guarantee that someone will be able to attend, but we can make education materials available for you to distribute.
Name of event
Purpose or theme of event
Event organizer
Type of event

Other
Event start time

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
Event end time

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
Location

Hybrid (please elaborate needs)
Requested role for MARC

other
Length of presentation requested (if applicable)
Topic of interest

other topic or combination of topics
Requested set-up start time
Will assistance be available for set-up?
Location name (if applicable)
Location Address (if applicable)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact name
Contact email
example@example.com
Contact phone
What needs to be provided?

other
Estimated attendance
Audience age range

other
Has a MARC program participated in this event in the past?
Please verify that you are human
Should be Empty: