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.

 

 

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


 

 

Please Indicate Service/Education Needed

 
 

Parking Lot with Electricity Needed

 

 
 
 
 
 
mm/dd/yyyy
 
 


Set up time / special restrictions

 
 


Choose audience size greater than options below.

 
 


Please enter a description of the Target Audience.


Examples: Seniors, Head Start, Churches, etc.


 
 
 
 

 
 
 
Phone