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Health Fair / Event Participation Request Form
Thank you for considering the Carroll County Health Department (CCHD) as your community partner!
CCHD can provide speakers, booths/displays, educational materials and/or various health screenings.
Preference will be given to events that:
Support the health and wellness of Carroll County residents and visitors.
Align with our mission, vision, and values which can be found at
CCHD.maryland.gov
.
Application Process:
Complete the online request form below.
A separate form should be completed for each event.
Please provide as much notice as possible, as later requests may potentially affect our ability to attend.
Allow 5 business days for a response.
Other:
Please contact the office of Health Education at 410-876-4448 if the event needs to be cancelled or re-scheduled.
We may be unable to fulfill every request, even if the organization meets the above criteria.
CCHD is unable to provide sponsorship, grant, or advertising requests.
After viewing this form, if you have any further questions about available programs, call 410-876-4448.
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* Indicates required question
Name of event:
*
Your answer
Event date:
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MM
/
DD
/
YYYY
Event Start Time:
*
Time
:
AM
PM
Event End Time:
*
Time
:
AM
PM
Event location and address:
*
Your answer
Contact Person:
*
Your answer
Phone:
*
Your answer
Email:
*
Your answer
Organization:
*
Your answer
Is there a vendor fee?
*
Yes
No
Will this event be sponsored by other organizations? If so, please list them below:
Your answer
Do you have a flyer or additional information for this event? If so, please email to Lauren.Harrison@maryland.gov.
*
Yes
No
What services are you requesting?
*
Booth/display table
Educational materials
Health screening
Speaker
Health On Wheels RV (for screenings)
Required
Select any
Health Education
topics that you would like represented:
Childhood Injury Prevention: Information and education on child passenger safety (including car seat checks), poison prevention, home safety, safe sleep, gun safety, & bike/pedestrian safety.
Highway Safety: Education on distracted/impaired/aggressive driving, occupant protection, and roadside safety.
Diabetes Prevention: Pre-diabetes screening along with education and programs on the prevention of type 2 diabetes.
Weight Loss: Information and education on healthy weight loss, including weekly meetings, accountability and support.
Tobacco and Vaping: Education on products, preventing youth use, and counseling for adults to quit smoking or vaping.
Public Health Preparedness and Response: Information and education about being prepared for emergencies.
Vital Records: Information about birth and death certificates.
Select any
Prevention/Treatment/Harm Reduction
topics that you would like to be represented:
Alcohol/Drug Education: Information on current alcohol and drug trends and initiatives to prevent drug use, misuse, and overdose.
Parent Resources: Information on preventing drug/alcohol use in youth.
Peer Support: Individual in recovery using lived experience to support others in their journey.
Harm Reduction: Information and materials on reducing negative or fatal consequences associated with drug use.
Naloxone Training: Training and materials for Naloxone.
Select any
Behavioral Health
topics that you would like represented:
Service Coordination: Connecting children, adolescents, and adults to appropriate services.
Mental Health First Aid: An evidence-based training on how to help someone experiencing warning signs or symptoms of a behavioral health illness or crisis.
Children's Mental Health Resources: Information on Children's Mental Health and local resources.
Resources for those experiencing homelessness: Information on local supports and services.
Select any
Health Services
topics that you would like represented:
STI/HIV/Hepatitis Education: Presentations, brochures, and information on STI's.
STI/HIV/Hepatitis Testing: Screenings for STI's, including Chlamydia, Gonorrhea, Syphilis, HIV, and Hepatitis C.
Sexual Health, including normal body development: Educational presentations on female and male reproductive health; presentations on puberty and normal development.
Contraception: Presentations and brochures on contraception.
Preventative Reproductive Health: Including preconception and cancer prevention education.
Lyme Disease: Awareness and education on Lyme Disease prevention.
Rabies: Human rabies treatment and education
Other Infectious Diseases: Awareness, education, and prevention on infectious diseases prevalent in Maryland.
Cancer: Breast, cervical, and colorectal cancer awareness and screenings.
Medical Assistance Transportation: Information about rides to non-emergency medical appointments for people with Medical Assistance.
Select any
Maternal Child Health
topics that you would like represented:
Infants and Toddlers: Brochures and information available about the program for infants and toddlers with special health care needs/diagnosed disabilities at risk for developmental delays.
Child Immunizations: Brochures and information available about immunization clinics for those children who have Medical Assistance, Medicaid, or who are Underinsured, Uninsured, or American Indian or Alaska Native.
Lead Program: Lead education information and case management depending on the lead level.
Home Births: Assistance with certifying home births.
Dental: Information about the dental clinic that is available to pregnant women and children (ages 1-18) that are enrolled in the Maryland Medical Assistance Program.
Select any
Environmental Health
topics that you would like represented:
Food Safety: Training and education on food safety related topics.
Rabies: Awareness and education on rabies prevention.
Any additional details that would be important for us to know about this event?
*
Your answer
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