"Jag Mobile" Mobile Health Unit Event Request
Event Name
*
Event Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Event Location (Address)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Event Set Up Time
*
1
2
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9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Event Begin Time
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Event End Time
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Number of Attendees Expected
*
Indoor Accommodations Available
*
Chairs
Table
Office
Work Room
Conference Room
Restroom
None
Other
Services Requested (*subject to change)
*
Blood Pressure Screening
Body Mass Index Screening
Mental Health Education/Awareness
Health Education
Glucose and Cholesterol Screening*
HIV/STI Testing*
Cancer Screening(s)*
Other
Event Flyer Upload
Browse Files
Cancel
of
Additional Information
Event Point of Contact
*
First Name
Last Name
Event Point of Contact Email
*
example@example.com
Event Contact Phone Number
*
-
Area Code
Phone Number
Secondary Event Point of Contact
First Name
Last Name
Secondary Event Point of Contact Email
example@example.com
Secondary Contact Phone Number
-
Area Code
Phone Number
Submit
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