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North Texas Poison Center Request for Health Fair/Lecture

Please fill out all required fields below.

Requesting Organization*
Address*
Street Address Address Line 2 City County ZIP / Postal Code
Contact Person*
First Last
Contact Email*
Phone*
Day of Event Contact Person*
First Last
Day of Event Contact Phone*
Type of Event*
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Duration of Event*
Audience*
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Event Date*
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Event Time*

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Event Location
- Same as Organization Address
Event Address*
Street Address Address Line 2 City County ZIP / Postal Code
Estimated Number of Attendees*
Venue Type*
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Will table and chairs be provided?*
- Yes
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Is a laptop and projector available for use at the venue?*
- Yes
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Spanish materials needed?*
- Yes
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Estimated amount needed*
Has the Poison Center done an event for this organization before?*
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How did you hear about us?*
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Special Instruction, Comments and Event Details*

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