Speakers Bureau, Health Fairs and Special Events Request Form

Main Administrative Office

941-861-2900
DOHSarasotaInfo@FLHealth.gov
Mailing Address
William L. Little Health and Human Services Center
2200 Ringling Blvd
Sarasota FL 34237

Please complete this form to request a guest speaker, participation in a health fair or special event, including the Health In Motion Mobile Medical Unit.

* These areas are required for your request to be considered.

Under Florida law, e-mail addresses are public records. If you do not want your e-mail address released in response to a public records request, do not send electronic mail to this entity. Instead contact these offices by phone or in writing.

Fields marked with an asterisk (*) are required.

Today's Date

Name of Event*

Nature of Request*

If "Other" please explain:

Type of Event*

If "Other" please explain:

Estimated Number of People Attending*

Program Location Name*

Address of Program*

Event Date*

Event Location*

Event Start Time*

Event End Time*

What other service providers be present?*

How will the event be promoted? Please include information on use of traditional media, social media, organizational emails or newsletters, and any other form of advertising?

Full Name*

Organization Name (if applicable)

Organization Address/City*

Contact Phone*

Contact Email

Please note: Florida has a very broad public records law. Most written communications to or from state officials regarding state business are public records available to the public and media upon request. Your e-mail communications may therefore be subject to public disclosure.

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