Event Request Form

Event Request Form

PLEASE NOTE: All event requests need to be submitted at least 30 days prior to your event. Events involving screenings and or testings must be submitted 45 days in advance.
Who is the internal contact requesting the event?*

First NameLast Name
E-mail:*
Phone:*
What school/organization/business is requesting the event?*

Name of event:*
Estimated attendance:*
TEST- SURVEY NOTIFICATION

MonthDayYear
Time frame for event:*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Date(s) of event:*
Event location:*

Street Address

Street Address Line 2

CityState

Zip Code
Who is the external contact person? (event host/organization)*

First NameLast Name
External contact phone number:*
Please enter a valid phone number.
Is this a clinical off-site event?*
Event description:*
Please give a brief overview of the event.
Marketing items needed & quantities:*
Registration links or website for your event:*
Registration forms/additonal information upload:

Allowed file types: pdf, doc, docx
Cancelof

Is this a nursing event?*
Does this event require physicals?*
Does this event require vaccines?*
Is this a billable encounter? (If you are unsure, please contact billing@arcare.net)*
Does this event require testing?*
*Please note: all events that require testing must be submitted at least 45 days in advance.

Please list who is working the event:*
For assistance staffing this event please contact the marketing department at marketing@arcare.net.
Please list any special requests:*
Should be Empty: