PARTNER APPLICATION
Chronic Disease Prevention
CONTACT INFORMATION
Applicant Name
*
Applicant Address
*
Address (Line 2)
City
*
State
*
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
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
SUBMIT
Should be Empty: