Community Outreach Form

BarnMD Community Outreach Request

Use this form to request a BarnMD-led outreach activity in your community.

Full Name*

Organization / Community Group Name*

Your Position / Role*

Email Address*

Phone Number*

Type of Outreach Requested*

Proposed Topic or Focus Area*

Target Audience*

Expected Number of Participants*

Proposed Venue & Location*

Preferred Date(s)*

Will your organization provide any of the following? (Check all that apply)
Venue
Volunteers
Security
Refreshments
Media/Publicity
None

Additional Notes or Requests

Authorized By (if different from requester)

Date of Request*

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