Public Education Application

Date Requested*

Start Time Requested*

:

End Time Requested*

:

Location of Event*

Address of Event*

Street Address Address Line 2 City Province Postal Code

Contact Name*

Organization*

Phone Number*

Email Address*

Audience Description*

Estimated Number of Participants*

Program

Requested Program*

Please explain

Audio/Visual Equipment Available*

Please identify your agency's objective or outcome measure.

Are there any audience members with disabilities who require special accommodation or presentation format?

Comments

This field is for validation purposes and should be left unchanged.