Community Event Participation Request Form - 4857407

MedStar Health Community Health Outreach Request Form

Date of Request*

Organization Name*

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Country

Organization Type*

Community/Civic Health Care Facility Education Health Related Faith Based Corporate/Business Government

Website

Please describe the mission of your organization.*

Please provide a historical overview of your organization.*

What type of support are you requesting?*

Health fair/Screening Speaker Event/Educational Materials

Other:

Please describe type of support you are requesting.*

Contact Information

Contact Name*

First Name

Last Name

Contact Title*

Contact Phone Number*

Contact Email Address*

Event Information

Date of Event*

Start and End Time of Event*

Name of Event*

Address of Event*

Address Line 1

Address Line 2

City

State

ZIP Code

Country

Type of Event*

Health Fair Clinic/Screening Health Talk Virtual

Other:

Please provide a brief description of the event.*

How will this event benefit the community?*

Audience*

Church Community Community organization School Workplace Virtual

Other:

Expected Attendance*

Event Site/Location*

Inside Outside Virtual

Event organizer will provide

Table Laptop Chairs Projector Tent (if outdoors) Access to an outlet

*if applicable

What other vendors/organizations will be participating? *

Please include any other pertinent information regarding this event

Upload File (event flier, vendor agreement, etc) No File Chosen

File uploads may not work on some mobile devices.

I have reviewed the guidelines and feel my request is aligned with MedStar Health community event participation criteria: *

I agree

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Campaign Term

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Campaign Content

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Campaign Name

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GCLID (Google Click Identifier)

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