Wellness on Wheels (WOW) Van Request Form
Thank you for your interest in requesting the WOW Van. Please submit this form at least 4-5 weeks prior to your event to ensure we can accommodate your request. A representative will contact you to confirm the details and availability of the WOW Van. If you have any questions, please contact Fernanda Guaman at fguaman@cmhacc.org.
Requestor Information
Name
*
First Name
Last Name
Organization/Department
*
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Confirm Email
*
example@example.com
Event Information
Event Name
*
Event Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Event Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Start Time
*
Hour Minutes
AM
PM
AM/PM Option
End Time
*
Hour Minutes
AM
PM
AM/PM Option
Describe the purpose of this event and why you are requesting the WOW Van:(e.g., health screenings, educational outreach, wellness workshops)
*
Estimated number of Attendees:
Requested Services
*
Wellness Education (nutrition, fitness, mental health, etc.)
Resource Distribution (pamphlets, informational materials)
Mobile Consultation Area
Other (Please specify below):
Any specific needs or accommodations required?
Submit
Should be Empty: