2.  The Aging and Disability Resource Center (ADRC) provides information on services and programs available to older adults, persons with disabilities, family members, and other caregivers in Prince George's County.  Would you like ADRC staff to participate in an upcoming community event?

4. Name*
6. Email Address*
7. Phone Number*
9. Organization
11. Address*
13. City*
14. State*
    -- Select One --AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
15. Zip Code*
17. Event Venue Type*

    1. Virtual
    2. Indoors
    3. Outdoors
18. Projected Number of Participants*
19. Is the Organization Address the same as the Event Address?*

    1. Yes
    2. No
21. Event's Address*
23. Event's City*
24. Event's State*
    -- Select One --AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
25. Event's Zip Code*
27. Event Date
    Event Date
28. Event Time*
    Event Time Start Time

    —

    Event Time End Time
30. Staff Arrival Time*
    Staff Arrival Time
31. Staff Departure Time (Estimated)*
    Staff Departure Time (Estimated)
33. Purpose of Request

    Select all that apply

    1. Information Table with Materials
    2. Audio/Visual Presentation
    3. Speaker or Workshop Presentation
    4. Community Event
    5. Community Education
34. Target Audience

    Select all that apply

    1. Seniors
    2. Faith-Based
    3. Community Group
    4. Adults 18+ with Disabilities
    5. Non-Profit
    6. Government
    7. Adults
    8. Youth
35. Topics of Interest

    Select all that apply

    1. General Information/Services & Programs
    2. Medicare/Insurance Information
    3. Housing for Seniors/Individuals with Disabilities
    4. Long-Term Care Planning
    5. Alzheimer's & Other Dementias
    6. In-Home Care & Assistance
    7. Family Caregiving
    8. Employment Services
    9. Volunteer Opportunities
37. Additional Information

    i.e. event set-up details, parking, presentation duration, additional topics or other information

39. Disclaimer

    The submission of this request does not guarantee DFS’ participation. A staff person will contact you by email to confirm whether DFS will participate. If the request is for exhibiting at your event, the sponsoring organization must supply tables and chairs as-needed.

Leave This Blank:


41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit

* indicates a required field