Request Form

Please complete the contact information and give specific details about the event in which you would like a mobile unit to be present. Please complete this form at least one month prior to the event date. Disclaimer Each completed form is delivered to every mobile unit within the Consortium. If a mobile unit is available, that mobile unit will contact your organization in a timely fashion.
Today's Date
Your Name
Telephone Number
Email Address
Name of Requesting Organization
Name of Event
Date of Event
Time of Event
Location of Event (name of location and address)
Description of Event
Is this an outdoor event?	Yes No
Is there adequate parking available for a mobile unit?	Yes No
How many people are expected to come to the event?
Target Population (children, women, elderly)
What type of Mobile Medical Services are you seeking? (check all that apply)	Primary Care Screenings Behavioral Health Screenings HIV/AIDS Testing Maternal and Children Health Care Immunizations Exercise Other
Is your organization a 501c3 organization?	Yes No
Anything else you would like to share with us about the event