Community Outreach Request – Headlands Research Detroit

Community Outreach Request Form

Organization Name(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Contact Name(Required)

First Last

Phone(Required)

Email(Required)

Event/Activity Name

Event Date

Event Start Time:

Event End Time:

Event Setting

Event Location

Type of outreach requested:

Request Description

Target Audience

Seniors

Adults

Teens

Children

Infants

Anticipated number of attendees

Do you provide any of the following? (please select all that apply)

Table(s)

Chair(s)

Tent

Electric A/V Equipment

CAPTCHA