2. Interested in having the Shelby County Division of Community Services participate in your community/health fair or send someone to speak at your event? Please complete the form to request our participation. Thank you!
4. Name of the Program/Event
6. Organization Sponsoring the Event*
8. Type of Event*

   1. Health/Community Fair
   2. Community Group Meeting
   3. Faith-based Event
   4. Class or Professional Presentation
   5. Other:
10. Name of Location*
12. Street Address*
13. Zip Code*
15. Date of the Event*
    Date of the Event
16. Time of the Event*
    Time of the Event Start Time

    —

    Time of the Event End Time
18. Target Audience
19. Expected Attendance
21. Contact Person's Name*
23. Email address*
24. Phone Number*
26. Check the department(s) below for participation in your event*

    1. The Aging Commission
    2. The Community Services Agency
    3. The Office of Justice Initiatives
    4. The Shelby County Crime Victims Center/Raper Crisis Center
    5. Veteran Services
    6. Multicultural/Hispanic Affairs
    7. Behavioral Health Unit of the Office of Justice Initiatives
    8. The Division of Community Services (representative of all departments listed above)
28. Other*
30. Items Provided by the Sponsor*

    1. Table and chairs
    2. Canopy or Tent
    3. Other:
32. Other Items*
34. I would like to have someone speak at this event.

    1. Yes

    1. No
35. Length of time for speaker
    Length of time for speaker Start Time

    —

    Length of time for speaker End Time
37. I would like for them to speak about:
39. I have some questions about the services offered by the Division of Community Services. Please connect me with information about:

    1. Assistance with finding services for a senior citizen.
    2. Emergency help with rent, mortgage or utilities.
    3. Special courts for persons with persistent mental health problems, A&D issues or for veterans.
    4. Help for persons who are incarcerated or awaiting a criminal trial.
    5. Services for victims of crime including counseling, court support and concrete social service needs.
    6. Rights, services, or programs for veterans.
    7. Specific needs of Spanish speakers in our community.
41. Would you like to be added to our email list to receive our monthly newsletter, Community Connections?

    1. Yes
    2. No
Leave This Blank:


43. 1. Receive an email copy of this form.
44. Email address

    This field is not part of the form submission.

45. Submit

* indicates a required field