Community Event Request
Request must be received at least 2 weeks prior to event date.
Your Name
*
First Name
Last Name
Your Organization Name:
*
Phone Number
*
Please enter a valid phone number.
Primary Contact Email
*
example@example.com
Is there an additional contact for this event?
*
No
Yes
Additional Contact Name:
*
First Name
Last Name
Organization Name:
*
Phone Number
*
Please enter a valid phone number.
Additional Contact Email
*
example@example.com
Event Title:
*
Type of Event:
*
Please Select
Community Baby Shower/Baby Expo
Car Seat Check Lane
Health Fair
Development Screening Event
Community Partner Event (DCF, Coalition, Trunk or Treat, etc.)
School/USD Event (Literacy Nights, Enrollments, etc.)
Family and/or Community Resource Event
Becoming a Mom
Guest Speaker/Presentation
Other
Other Event:
*
Event Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County:
*
Please Select
Clark
Finney
Ford
Grant
Gray
Greeley
Hamilton
Haskell
Hodgeman
Kearny
Lane
Meade
Morton
Ness
Scott
Seward
Stanton
Stevens
Wichita
The Event is:
*
Indoor
Outdoor
Event Date & Time:
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Is there a separate set up time?
*
Yes
No
Unsure
Set Up Date & Time:
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Length of Event:
*
Anticipated Number to Serve:
*
Target Audience
*
Prenatal women/families
Families with children 0-3 years old
Families with children 3-5 years old
Families with children 6-12 years old
Teens/Adults/Older Adults
Would you like more information about our programs?
*
Yes
No
Topics To Be Discussed:
*
Car Seat Information
Safe Sleep
General RCDC Programing Information
Triple P/Positive Parenting
Growing Together
ABC
Learn & Play
Early Intervention
Mental Health
Other
What is provided?
Tables
Chairs
Electricity
Other
Are there special instructions for this event or location?
*
Attach a Flyer:
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