Women's Reproductive Health -- Feminist Women's Health Center

Cliff Valley Clinic • Division of Reproductive Medicine • Community Education & Advocacy Network (CEAN)
1924 Cliff Valley Way, Atlanta, GA 30329 • Clinic: 404-728-7900 • 1 (800) 877-6013 • CEAN/Administrative: 404-248-5445

Photo montage of young women with caption "Leading. Educating. Advocating."

Request for an Informational Table

Please fill in this questionnaire to request an informational table from FWHC. Items in red with an asterisk (*) are required.

* Your Name

* From (group, college, etc.)

* How did you find us?

* email address
(We promise not to give your email address to anyone else!)

*Phone number

Home Work Mobile

Alternate phone number

Home Work Mobile

*Dates & times requested (include back up dates, indicate priority)

Priority	Date	Time

*Location

*Type of Table Requested (put a check next to appropriate one(s))

Health Fair	Festival Table	Conference Table
Rally Table	Event Table
Other

Is there are charge for this table? (Please select) No Yes How much?

Are you providing the table, chairs and other items? No Yes

If so, please tell us the table size, # of chairs, and items, etc.

Are there any requirements to abide by? (select all that apply)

Restrictions on Selling Items	Restrictions on Raising Money
Restrictions on Offering Food	Restrictions on Offering Drinks
Restrictions on Including Information on

Expected Attendance? (insert number)

Group Demographics?

*Need Confirmation by (date)

Nearby Parking Availability (please explain)

Other Information?

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Feminist Women's Health Center
Cliff Valley Clinic * Division of Reproductive Medicine * Community Education & Advocacy Network (CEAN)
1924 Cliff Valley Way, Atlanta, GA 30329
Clinic: 404.728.7900 or TollFree 800.877.6013
CEAN & Administrative: 404.248.5445

The Feminist Women's Health Center is a member of Georgia Shares, an employee giving program.