*

Name of organization or church

*

Name of person submitting request

*

Phone number

*

Email address

*

Event name

*

Event date & time

*

Event location

*

Number of attendees expected

*

Is the event in-person or virtual?

in-personvirtual

If in-person, are table/chairs provided?

YesNo

If so, what length is the table?

*

Is the event indoors or outdoors?

If outdoors, do you provide a tent?

YesNo

Please indicate below any services you want to request for your event.

Screenings:

Blood Pressure
Diabetes Risk Test (not glucose test)
HIV Testing
BMI Screening
Fall Prevention

If you are requesting cancer information, please specify type of cancer.