Event Request Form

We look to partner with organizations to show health outcomes and create equity in care.

Event Timing

In order to prepare and staff events, requests must be made at least 12 weeks prior to your event.

Yes, my event is at least 12 weeks from now.

Organization Information

Type of Organization Organization Name Organization Contact Phone Email

Event Information

Engagement description and purpose Health outcome desired Requested Services

If this request includes use of the mobile unit, does your location have a flat space, access to electricity and a large open space?

Yes Date(s) of Event Hours of Event Event Location and address Expected Attendance