Community Outreach Request


NOTE: Items with an asterisk (*) must be completed prior to submitting!




Your Name:(*)

As the submitter, you must include your first and last name

Name, Date and Location of Event:(*)

Please enter the name, date and location of the event.

Event Setup Time:(*)

Please include an event setup time

Event Start Time:(*)

Please include a start time for your event

Event End Time:(*)

Please include an end time for your event.

Rain or Snow Date:


Please select the rain / snow date for your event

Site has liability insurance?(*)


Please confirm whether or not the site has liability insurance.

Insurance Provider Details:(*)

Please provide the details for your Liability Insurance Provider for the event

Type of Parking:(*)

Please include the type of parking

Parking Fee?(*)


Please tell us if there is a fee to park

If Yes, Fee Waived for Staff?(*)


Is the parking fee waived for staff?

Event Contact Name and Title:(*)

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Event Contact Phone:(*)

Please include a valid phone number

Event Contact Cellphone:(*)

Please enter a valid cellphone number for the event contact

Event Contact Office Number:

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Other Phone:

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Event Contact Email:(*)

Please include a valid email address

Day of the Event Contact Person Name:(*)

Please let us know the name of the contact person the day of the event.

Contact Phone:(*)

Please include a valid number for the contact person the day of the event.

Contact Cell Phone:(*)

Please include a cell phone number for the contact person the day of the event.

Company Health Insurance Provider (if place of employment) (*)

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Electricity Available?(*)


Please confirm whether or not electricity will be available the day of the event.

Wireless/Wi-Fi Available?(*)


Please confirm whether or not wi-fi is going to be available the day of the event.

Estimated attendance:(*)

Please give us an estimate of how many you expect to have in attendance. (numbers only)

Language and cultural needs (explain):(*)

Please elaborate or simply include "N/A"

Are you currently working with AtlantiCare on other initiatives or programs? (*)


Please confirm whether or not you're working with AtlantiCare on other initiatives or programs.

Details of your work with AtlantiCare:(*)

Please tell us about your current work with AtlantiCare

AtlantiCare Contact:

Please include the name of the AtlantiCare Contact you're working with in your program.

Event Audience:(*)









Please tell us the expected audience
Check all that apply.
How is the event being promoted?(*)




Please tell us how you're promoting this event.
Select all that apply


Purpose of Event (what are your main objectives of event)?(*)

Please tell us the Purpose of Event, what are your main objectives of event

To help us avoid computerized spam, please type in: (*)
To help us avoid computerized spam, please type in: 

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NOTE: This is an event request and does not constitute a confirmation, or commitment to attend or provide all services requested.
Please allow a 45 day lead in order to secure appropriate services.



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