CHAMP Mobile Mental Wellness Clinic Service Request

CHAMP Mobile Mental Wellness Clinic Service Request
Name*

FirstLast
Company/Agency/Organization
E-Mail*
Phone Number*
Date Needed For Your Event*

MonthDayYear
Date
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 company and the programming requirements associated with your request.
Agree to terms*

I understand and agree that a service fee between $300–$500 will be applied once the agreement is finalized.
Should be Empty: