Southern Jersey Family Medical Centers
Community Outreach Event Request Form
Name of Organization
Event Name
Describe your event and objective. ( What type of event i.e. health fair, community forum, etc. What is the purpose or goal of the event?)
Who is the audience who will be attending the event? ( i.e, students, families, politicians, community members etc. )
Date of Event
-
Month
-
Day
Year
Date
Event Start Time
Hour Minutes
AM
PM
AM/PM Option
Event End Time
Hour Minutes
AM
PM
AM/PM Option
Expected Number of Attendees
Address of Event
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Name
First Name
Last Name
Contact Title
Contact Email
example@example.com
Contact Phone Number
Please enter a valid phone number.
Services Requested
Blood Pressure Screening
Finger Stick- Diabetes
Testing
Vaccines
Insurance Enrollment
Education
Giveaways
Mobile Medic
Other
What Supplies is SJFMC required to bring to event?
Tables
Chairs
Tents
Other
File Upload
Browse Files
Drag and drop files here
Choose a file
Please attach an event flyer or a formal request letter.
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of
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