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 Program | Event*
6. Organization Hosting the Event*
8. Type Of Event*

   1. Class or Professional Meeting
   2. Community Fair
   3. Community Group Meeting
   4. Faith-Based Event
   5. Health Fair
   6. Radio or Podcast
   7. Other
10. If you chose other, please specify:
12. Will this be in-person or virtual?*

    1. Virtual
    2. In-Person
    3. To be determined
13. Will the presenter have slideshow capabilities?*

    1. Yes
    2. No
15. Where will this in-person event be located?*

    Street Address, City, State, Zip-code

17. Items provided by organization:*

    1. Table and Chairs
    2. Canopy or Tent
    3. Other
19. If you chose other, please specify:
21. What platform will be used to host the event?*

    Eg: Zoom, GoToMeeting, Microsoft Teams...

22. Access link to event information, if available:
24. Date of the Event*
    Date of the Event
25. Time of Event*
    Time of Event
26. Duration of time for presenter*
28. Expected Number of Attendees*
29. Target Audience*

    Staff Members, Residents, Church Congregation, Students, etc.

30. Target Area*

    Frayser, South Memphis or Zip codes: 38127, 38126, 38119

32. Contact Person's Name*
34. Email Address*
35. Phone Number*
37. Check the service(s) below that you would like to participate in your event:
39. The Aging Commission

    1. Serve Seniors and Adults with disabilities

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

41. Community Services Agency

    1. Financial assistance, serving residents that want to break free of the poverty cycle

    Rent/mortgage, utility, medical prescription assistance, and family support self-sufficiency program

43. Crime Victims & Rape Crisis Center

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

    Sexual assault forensic exams and advocacy, counseling, support groups, court accompaniment, filling for victim's compensation 

45. Veteran Services

    1. Serving Veterans and their families

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

47. 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 illnesses in the system

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

Leave This Blank:


49. 1. Receive an email copy of this form.
50. Email address

    This field is not part of the form submission.

51. Submit

* indicates a required field