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Project ARK Presentation Request Form
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Today's Date
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MM
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DD
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YYYY
Your Organization/Group Name
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Your answer
Proposed Presentation Date
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MM
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DD
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YYYY
Type of Event
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Health Fair
Health Fair + HIV Testing
Presentation
Presentation + HIV Testing
Required
Location of Presentation
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Your answer
Number of Presentations
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Your answer
Time Alloted Per Presentation
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Your answer
Approximate Number of Participants
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Your answer
Age Range of Participants
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Your answer
If participants are under the age of 16 years or younger, is a parent/guardian permission form needed?
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Yes
No
N/A - all participants are above age 16
Choose Presentation Topic
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Choose
HIV/AIDS Basic Facts – Introductory education to how HIV transmission, prevention, and treatment
Prevention skills – Education about how to educate and empower self to achieve sexual health goals (preventing or becoming pregnant, remaining STI free, using condoms, remaining abstinent)
STI Basic Facts – Education about common sexually transmitted infection transmission, prevention, and treatment (HIV, syphilis, gonorrhea, chlamydia)
Project ARK or The SPOT – Overview of our program and community services
Any special concerns or sensitivities regarding the discussion of HIV/AIDS and/or condoms?
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Your answer
Can we provide a condom use demonstration?
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Yes
No
Would like to discuss further
Contact Person
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Your answer
Contact Person's Phone Number
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Your answer
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