LifeBridge Health Community Services Request

Please Note:

Please request 6-8 weeks prior to date of event

Completion of this application does not guarantee participation in this event.

Participation is based on staff availability.

LifeBridge Entity*

For ALL Mobile Services requests, please be sure to pick Grace Medical Center as the LifeBridge Entity.

Service Type*

Pediatric Mobile Health Services

Community Health Services

Community Health Services - Mobile Unit Needed?

Parking Lot with Electricity Needed

Yes

No

Name of Event*

Address of Event*

Event Zip Code*

Event Date*

Location (indoor/outdoor)*

Both

Inside

Outside

Special Considerations:

Set up time / special restrictions

Target Audience Demographic*

Please enter a description of the Target Audience.

Examples: Seniors, Head Start, Churches, etc.

Brief Description of Event:

Contact Name*

Contact Email Address*

Phone Number*

Phone

Sponsoring Organization*