Wellness Health Fair Request Form Complete this form to request that CoxHealth Total Wellness professionals participate in your health fair. * Required Fields Organization/Business Name * Health Fair Contact Name/Title * Work Street Address * City, State, Zip * Email Phone * Date of Health Fair Example Format: MM/DD/YYYY Location of Health Fair Theme of Health Fair Start/End Time Cost to Participate (if applicable) Drawing Item Requested Time of Set-Up Booth Size/Space Allocated Are any of the following provided? * Chairs Tent Tablecloths Table Skirts Electricity N/A Target Audience Number of Participants/Attendees Expected Health Fair Goals Is there an opportunity for a speaker? Yes No List health care providers participating How will the health fair be promoted? Specific/Special Requests leave this field blank to prove your humanity