Community Outreach Request

In which county will the event/presentation take place? *

If your county is not listed, you may need to reach out to another Planned Parenthood affiliate by visiting PlannedParenthood.org.

Organization or Group Name *

Organization/Group Address *

Organization/Group Website *

Contact Person’s Name *

Contact Person’s Title *

Email *

Phone *

Request Details (time/date): *

If there is a specific date and time for the event/presentation please list that information in the “request details” box above. Please be as detailed and specific as possible. (For example: “The event is on May 5th, from 12pm to 3pm” or “We would like the presentations for our students before the end of July. I teach 3 periods of 9th grade classes on Mondays and Tuesdays from 9am to 12pm.”)

Address of Event/Presentation: *

For presentations, please tell us about what you would like covered or accomplished:

How many people will be attending the presentation/event? *

Tell us more about the audience (ages, genders, other demographics): *

What else would you like to tell us about your request?

Are you a robot? *