Police Outreach Request

Coordinator/Contact Person Name

Title

Phone

Fax

Email

Organization

Address

Topic/Type of Program Requested

Describe Format (Stationary exhibit, lecture, roving lecture, demonstration, discussion etc.)

Date Requested

Please select a date at least two days in the future.

Time Requested (Start and Finish)

Projected Attendance

Age Range

Event Location (address)

Individuals with disabilities require accommodation

Yes No

Describe

Other Information (details that may assist us in preparing to serve your audience)

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