Education and Program Request

To request presentations, educational curriculums (youth), group classes, or general inquires please complete the below form.

Please note that health educators request at least two weeks prior notice the date of event/presentations. We may not be able to accommodate on shorter notice.  

If Selecting Car Seat Education as a topic please note that this does not include distribution of (1) donated car seat per family. Individuals must contact 423-209-8204 to program details and to schedule an appointment.

 

o   Date and Time of Requested Presentation

 

o   Name or Point of Contact of Requester

 

 

o   Requesting Organization Name and Address

 

o   Topic Request and Type  (Drop Down Menu)

o   Adult Nicotine Cessation Group Counseling

o   Adult Vaping/Tobacco Education

o   Athletes As Leaders (Female Sport Teams)

o   Battle of the Belt (Highschools Only)

o   Bystander Intervention

o   Car Seat Education (Presentation Only)

o   Checkpoints for Teen Driving

o   Chronic Disease Self-Management Program

o   Chronic Disease Prevention Presentation (Specify in Comments)

o   Coaching Boys Into Men (Male Sport Teams)

o   Healthy Eating and Active Living

o   Highway Safety (Specify in Comments)

o   Nicotine Free Team Sports (Youth Sports)

o   Safe Dates

o   Safe Bar

o   Safe Routes to Schools

o   Shifting Boundaries

o   Youth Vaping/Tobacco Education

o   Youth Nicotine Cessation Group Counseling (School Setting)

o   Other____ Please Specify in Comments Section

Expected attendance

 

How much time is allocated for presentation/class/etc.?

 

What materials and equipment will you be able to provide? (Wifi, projector, screen, microphone, etc.)

Audience Type (Students, Adults, Parents, etc.)

If for students, or parents and caregivers of students  what is the grade level?

Facility Type (Gymnasium, Library, Classroom, Outdoors, etc.)

Comment: Please provide any additional details