Request to Participate

Request to Participate
Thank you for your request for Black Nurses Rock Orlando to participate in your event. It is an honor that you have considered to include us. Our mission is to empower nurses to be innovative and to educate the vulnerable communinities that are affected by health care disparities.

While we are nurses and are able to take blood pressures, our focus is on providing education on HIV/AIDS. diabetes, cancer, healthy behaviors, and high blood pressure.
Title of Event:
Date of Event

MonthDayYear
Date
Start-time of Event

:HourMinutesAM/PM Option
End-time of Event

:HourMinutesAM/PM Option
Location of Event*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Please indicate specific roles that you would like for us to perform at your event.
Is the event indoor or outdoor?

IndoorOutdoor
What equipment do we need to bring?*

TableChairsTent
Is there access to electricity?

YesNo
Is there a vendor fee?

YesNo
Contact person from your organization.*

First NameLast Name
Number of nurses needed?
Phone*

Area CodePhone Number
E-mail*
By completing this form it does not confirm our participation. The event will be reviewed and voted on by the Executive Board. Please allow 2 weeks for review of submitted request.

Approved events would require the following:

Two tables (one to display our information and the 2nd table for providing blood pressures).

Thank you
Should be Empty: