Request Participation in a Health Fair or Community Event

To request Prevent Blindness Texas (PBT) participation in a health fair/community event, please complete this form and submit as directed below. Submission of this form DOES NOT guarantee PBT participation in your upcoming event. Participation is based on staff and/or volunteer availability and focus area of our programs. If PBT is able to attend your event, we will fax or email CONFIRMATION notice.

If you would like Prevent Blindness to conduct vision screenings at your event, please be prepared to provide the following:

2 tables, 6-8 chairs
Small trash bin
Electrical outlet for 2 equipment items
Quiet indoor location (away from bright daylight)


 









 Contact Name (required)

 

 Email Address (required)

 

 Phone Number (required)

 

 Event Type (required)
	
	

 Please provide the name of the event (required)

 

 Date of the event (required)

 

 Please provide the start and end times for the event (required)

 

 Please provide the address of the event (street address, city, state)

 

 What time can setup begin? (required)

 

 Indoor or Outdoor Event? (If the event is outdoors, we can only provide an info booth) (required)

 

 Name of Organization Requesting the Screening (required)

 

 Organization Address (If different than event address)

 

 Name of Sponsoring Company (If different than organization)

 

 Parking/Unloading Equipment Instructions (required)

 

 Will refreshments be provided? (required)
	yesno
	

 If yes, please specify

 

 This event is designed for which system? (required)
	
	

 Estimated Attendance (required)
	
	

 What population(s) will primarily be served at the event? (required)
	
	

 What age range(s) will be served? (required)
	
	

 What language does the expected population primarily speak? (required)

 

 Will an interpreter be available? (required)
	yesno
	

 What medical/vision coverage does the expected population have? (required)

 

 In the event that a Prevent Blindness Texas representative is not able to attend your event, would your organization still like educational materials sent to the organization address? (required)
	yesno