Mobile Community Health Unit - Request form
Thank you for your interest in our mobile Community Health Unit. Please complete the following form and a team member will contact you.
Contact information
Name of company or organization
*
Contact name
*
First name
Last name
Title
*
Phone number
*
-
Area code
Phone number
Email address
*
example@example.com
Event details
Title of your event
*
Date
*
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Month
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Day
Year
Date
Event location
*
Event address
*
Vendor setup time
*
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Hour
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40
50
Minutes
AM
PM
AM/PM Option
Event start time
*
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Hour
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Minutes
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PM
AM/PM Option
Event end time
*
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:
Hour
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10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Event questions
Will your event be targeting a specific audience?
*
How many attendees are you expecting?
*
How many vendors are you expecting?
*
What other health screenings will be offered at your event?
*
Provide summary of project with the name of programs or services.
How are you advertising your event?
*
Provide summary of project with the name of programs or services.
If needed, will your facility be available for use (restrooms, power, etc.)?
*
Provide summary of project with the name of programs or services.
Is parking available to accommodate our mobile unit (30'L x 10'W x 10'H)?
*
Yes
No
Are power outlets available outside of the event venue?
*
Yes
No
Are tables and chairs provided for vendors? If so, how many?
*
Attachments
Browse Files
Please attach relevant documents, event flyer, etc.
Cancel
of
Additional notes
Is there any additional information you would like us to have?
Submit
Should be Empty: