Streaming Request Form

Streaming Event Information

1. Proposed Date:

2. Alternate Date (if applicable):

3. Select a Start Time: (00:00 AM)

4. Select an End Time: (00:00 PM)

5. Time Zone:

NOTE: Most of Arizona does not observe Daylight Saving Time. From March to November, Arizona (outside of Navajo Nation) is aligned with Pacific time due to Daylight Saving Time. Navajo Nation follows Mountain time year round.

6. Title of Event

7. Short Description

8. Event Location/Event Website Link (if applicable)

9. Is your program able to support the travel costs of the IHS Tele-education staff to attend your event to facilitate the virtual streaming?(Please Select one):

10. Contact Information

Organizer Name/Credentials:

Organization/IHS Department:

Email Address:

Phone Number:

11. Comments/Additional Information, or questions?