CHAMP Mobile Mental Wellness Clinic Service Request

CHAMP Mobile Mental Wellness Clinic Service Request
Name*

FirstLast
Company/Agency/Organization
E-Mail*
Phone Number*
Format: (000) 000-0000.
Requested Service Type

Please select the service you are requesting from CHAMP. Some services may include a programming fee depending on the level of support requested.
Mobile Mental Wellness Clinic (Programming Fee Applies)Community Tabling / Resource Table (Free Service)
Please Note: Community tabling and informational outreach are provided at no cost. Requests involving the Mobile Mental Wellness Clinic or specialized programming may include a one-time service fee ranging from $300–$500, depending on the size and scope of the event.
Date Needed For Your Event*

MonthDayYear
Timeframe (How long do you need the mobile clinic) *

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Total 0.0
Tell us about your event (purpose, targeted population & location, etc) *
By submitting this form, you acknowledge and agree that once the agreement is finalized, a one-time service fee will apply. The service fee will range from $300 to $500, depending on the size of your organization and the programming requirements associated with your request.
I understand and agree that a service fee between $300–$500 will be applied once the agreement is finalized.
Should be Empty:

Requested Service Type