CONSORTIUM FOR A HEALTHIER MIAMI-DADE

CHOP - Community Health Outreach Program

Title of Event: *
Address of Event Site:
City:
State:
Zip Code:
Date of Event: * Date Format: MM-DD-YYYY
Start Time:
End Time:

Event Sponsor: Lead Organization's Name:

Event Planner's Name: *
Title:
Daytime Telephone: *
Mailing Address:
City:
State:
Zip Code:
Fax:
E-mail: *
Date Booth Registration Due by: Date Format: MM-DD-YYYY
Booth Fee(s) (if any):
Contact Person for Booth Registration:
Daytime Telephone:
E-mail:

Adult Immunizations

Diabetes Education

Nutrition

Arthritis

Domestic Violence

Prostate Cancer

Asthma

Family Planning Info

Safer Sex Materials

Blood Pressure

Glucose Testing

Sexual Assault

Breast Cancer Info

Healthy Start

Sickle Cell

Breastfeeding/WIC

Hepatitis Education

STD Education

Cervical Cancer

Hepatitis Testing

STD Testing

Child Immunizations

HIV Education

TB Education

Cholesterol

HIV Testing

Teen Clinic Info

Dental

KidCare Info

Tobacco Cessation

Chronic Disease Prevention (Specify)
Environmental Health (Specify)
Mental Health (Specify)
Presentations (Specify)
Social Services (Specify)
Other Services (Specify)
Prohibitions?
(E.g. condoms, safer sex materials)

Site Accommodations for Health Providers (Vendors):

Indoor
Outdoor
Rain Shelter
Bathrooms
Private Area for Confidential Screening Available?
Electricity
AV Equipment
Refrigeration (for Vaccines, Test Supplies)
Refreshments YesNo
Details For Vendor Parking
Location of Vendor Check-in Table & Site Map
Time for Vendors to Set Up
Is Set Up Assistance Available?
Breakdown Time?

Strategy to Attract Attendees:

Coordination With What Other Organizations?
Open to the Public?
Any Cost?
What Entertainment Provided?
What Children's Activities?
What Radio and/or TV Spots?
Newspaper Announcements?
Flyers Distributed to Other Organizations Well in Advance?
Who Will Canvass Neighborhood With Flyers?
Who Will Post Signs in Key Neighborhood Spots?
Other Marketing Activities?

Comments (Please include special instructions):