Chronic Disease Prevention - Partner Application

PARTNER APPLICATION

Chronic Disease Prevention

CONTACT INFORMATION

Applicant Name *

Applicant Address *

Address (Line 2)

City *

State *

ZIP Code *

Contact Name *

Contact Title *

Contact Phone *

Contact E-mail *

ORGANIZATION

Describe your organization, including mission and recent accomplishments *

Describe what you do to promote chronic disease prevention and education *

What is the prevalence of diabetes (if known) in your area?

What is the prevalence of cardiovascular disease (if known) in your area ?

What is the prevalence of hypertension (if known) in your area?

What is the prevalence of kidney disease (if known) in your area?

DESCRIPTION OF SCREENING EVENT

Name of Event *

Date(s) of Event *

Event Hours *

Event Address *

Event Address (line 2)

Event City *

State *

ZIP Code

How many years has the event been held? *

Expected # of Attendees *

Have you partnered with Bridge of Life before? *

Yes No

If so, in years past did you make referrals to local specialists if needed? *

Yes No

Is there a cost for Bridge of Life to participate in the event? *

Yes No

If yes, how much?

Can the fee be waived?

Yes No

Describe the event (please give a short summary) *

Describe the goals of the event *

Will there be other health screenings at the event (please specify): *

Describe the space for the screenings in detail (including size): *

Can you provide table and chairs at the event? *

Yes No

If so, how many tables?

If so, how many chairs?

Does the event location have the infrastructure in place to perform urine tests on patients?

Yes No

Will this event be exclusive to a certain group of people? *

Yes No

Describe the demographics served at the event? *

What are the primary languages spoken by the participants?

Do the majority of the participants have health insurance? *

Yes No

Can you provide referrals for care if needed?

Yes No

How will individuals be referred to a specialist if necessary?

Can you provide any volunteers to support the screening? *

When is the deadline to get confirmation on Bridge of Life’s participation? *

Other information we should be aware of