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Health Fair/Special Event Request

Center for Community Health

 Site Information
Note: all fields marked with an * are required
Community    Corporate    Senior

Name of event: 
* Date of event: 
(Please note, a 45 day notice is required.)
Time of event: 

* Organization name: 
Address: 

* Person Making Request: 
* Phone #: 
Email: 

* Event Contact Person: 
* Phone #: 
Email: 

Is this a new event? 
Yes  No
   If not, what was
last year's participation?

If corporate event,
please list your company's
insurance provider: 
Are any other health
care providers involved? 		 Yes  No
Will there be any advertising
or media coverage? 		 Yes  No
If yes, then
please provide details:
Will you have
volunteer support? 		 Yes  No


 Request for (check the best category):
Health fair support
Screenings (request specific screenings below)
Lunch and learn
Other (describe)
 Target Audience (check all that apply):
Children/teens  Adults  Seniors  All ages
Male  Female  Both

Estimated attendance:  
Additional information:
NOTE: Receipt of submission does not guarantee participation. We will contact you within five (5) business days. Please remember that a 45 day notice is required for all events.



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