EOHHS-MCDHH

Step 1 of 2

50%

Online Request Form

Requestor Information

Name(Required)

First Last

Position Title(Required)

Organization(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Fax

Email(Required)

Alternate Contact on Day of Service(Required)

Yes

Alternate Name

First Last

Alternate Mobile Phone

Alternate Email

Training Event Information

Requested Topic(Required)

Type of event(Required)

If other, enter:

Remote or Onsite Event Preferred(Required)

Remote

Onsite

Purpose of Event

Proposed Date

MM slash DD slash YYYY

Proposed Time

Hours

Minutes

AM/PM

Floor

Room

Location(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone

Target Audience(Required)

If other, enter:

Number of Attendees(Required)

Please note we can only provide trainings to groups of 10 or more individuals.

Will there be participants/attendees who are Deaf or hard of hearing? (Please note It is the requestor's responsibility to provide communication access for their participants/attendees)(Required)

Yes

Logistical Information

Does the training room have publicly accessible Wi-Fi available for use by trainers?(Required)

Yes

Can you provide us with a display device for presentation?(Required)

Yes

Please specify your display device.(Required)

Screen/Projector

Monitor

How would you like for MCDHH to connect to your display device?(Required)

MCDHH laptop (requires HDMI input)

Use existing laptop at location (this will require MCDHH to insert USB flash drive)

Does your display device have audio playback capabilities?(Required)

Yes

Do you have electrical outlets at the front of the presentation room?(Required)

Yes