Request Form for Speaker, Presentation, or Table for your Event

2. Thank you for your interest in having Shelby County Community Services participate in your event. Please complete this form to request our participation.

4. Name of the Program/Event*

6. Organization Sponsoring the Event*

8. Type of Event*

   1. Community Fair
   2. Health Fair
   3. Community Group Meeting
   4. Faith-based Event
   5. Class or Professional Meeting
   6. Other:

10. Other Event Type*

12. Name of Location*

14. Street Address*

15. Zip Code*

17. Date of the Event*
    Date of the Event

18. Event Start Time*
    Event Start Time

19. Event End Time*
    Event End Time

21. Target Audience*

22. Expected Attendance*

24. Items Provided by the Sponsor*

    1. Table and chairs
    2. Canopy or Tent
    3. Other:

26. Contact Person's Name*

28. Email address*

29. Phone Number*

31. I would like to have someone speak at this event.*

    1. Yes

    1. No

32. Speaker Start Time*
    Speaker Start Time

33. Speaker End Time*
    Speaker End Time

35. I would like for them to speak about:*

37. Check the service(s) below for participation in your event

39. The Aging Commission

    1. serving seniors and adults with disabilities

    Adult day care, meals, home modification or repair, legal assistance, medical equipment, elder abuse prevention, senior centers, state health insurance programs, and transportation

41. Workforce Investment Network (WIN)

    1. serving job seekers and providing a qualified workforce for employers

    Job training and search tools, career development programs for youth and young adults, and business services to attract and retain employees

43. Multicultural/Hispanic Affairs

    1. serving all ethnic groups living in Shelby County

    Assistance and empowerment to all ethnic groups acting as liaison between government agencies and other groups to improve policies, programs, and services

45. The Community Services Agency

    1. serving residents trying to break free of the poverty cycle

    Utility and mortgage assistance, medical prescription assistance, family support self-sufficiency program

47. Crime Victims & Rape Crisis Center

    1. serving victims of crimes including domestic abuse, gun violence, sexual assault

    Sexual assault forensic exams and advocacy, counseling, support groups, court appointments, filing for victim’s compensation

49. Veterans Affairs

    1. serving veterans and their families

    Education and training, guaranty home loans, filing claims, burial benefits, educational assistance for dependents

51. The Office of Justice Initiatives

    1. serving residents who face possible incarceration for low level offenses or who have been previously incarcerated and those with mental illness in the system

    Pretrial Services as alternatives to incarceration for low level crimes including youth. Behavioral Health Unit response to residents with mental illness at any stage of the criminal justice system

Leave This Blank:


53. 1. Receive an email copy of this form.
54. Email address

    This field is not part of the form submission.

55. Submit

* indicates a required field