LOUISVILLE METRO DEPARTMENT OF PUBLIC HEALTH & WELLNESS
COMMUNITY HEALTH EVENT REQUEST FORM
The Louisville Metro Department of Public Health & Wellness is pleased to work with you to support and
empower people to lead healthy lives. Please take a few moments to complete this form, which will aid us
in serving you and the people who will attend your event. As a non-profit organization that offers free
services, we request a waiver of fees when asked to participate in community events.
ALL COMPLETED REQUEST FORMS PRIOR TO SCHEDULED EVENT ON A
FIRST COME FIRST SERVE BASIS EITHER BY:
1. FAX 2. U. S. MAIL 3. COMPUTER EMAIL
Office Phone: (502) 574-6585 LMDPHW Community Health Education Contact Us
Office Fax: (502) 574-6810 400 East Gray Street, Louisville, KY 40202
The Department has limited staff, but is always able to provide health education materials for events.
We are unable to provide screenings for blood pressure, cholesterol and glucose, but we do offer
lead screenings in the blood for children under 6 years old (Please call 574-6644 for more
information); and HIV/AIDS Screenings. (Please call 574-5600 to learn more about HIV/AIDS Education
and screenings). Click here to access a request form, resources for planning, implementing Community
Health Education Resources by topic area. Click here to learn more and complete a request for a display.
PLEASE CHECK THE BOXES BELOW TO INDICATE TOPIC(S) OF INTEREST TO YOUR PARTICIPANTS
Literature Presentations/Speakers Booth/ Displays
Abstinence Education Abstinence Education Abstinence Education
Family Planning Family Planning Family Planning
Breastfeeding Breastfeeding Breastfeeding
Diabetes Diabetes Diabetes
Disaster Preparedness HIV Education/Awareness HIV Education/Awareness
Lead Education/Prevention Lead Education/Prevention Lead Education/Prevention
Nutrition/Healthy Eating Nutrition/Healthy Eating Nutrition/Healthy Eating
Mosquito Control Tobacco Tobacco
Osteoporosis Weight Control Weight Control
Event Sponsor(s)/Sponsoring Agency/Organization:
Contact Name Title:
Email Address: Phone/Fax:
Date(s) of Event: Event Starts:
Vendor Set-Up Time: Event Ends:
City and Zip Code:
1. Are there any other holiday or community events scheduled on the same day that might impact attendance at
2. What are the most important health issues for your audience?
3. What are your expected total attendance, target audience, and age groups?
4. Does the event location offer rest room availability, accessible parking, ramp accessibility, rain shelter, electricity,
private area for screenings, and running water?
5. Is the event held indoors or out doors?
6. Could we post your health event on our metro public website?
For Official Use by the Community Health Education & Promotion Office
Request Assigned to: