Live Well on Wheels (Live WoW) Request Form

Live Well on Wheels (Live WoW) Request Form

For your request to be considered, the following requirement must be met: ensure you have reserved a location large enough to accommodate the vehicle (L 45' W 15' H 13').
Check the mobile calendar for availability at: https://www.livewellsd.org/i-want-to/find-resources/live-well-on-wheels-bus

The County of San Diego can provide proof of insurance for the vehicle upon request.

**Disclaimer: Approved events and services are subject to modification/cancellation based on county emergencies and availability.**

I have read and met the 2 minimum requirements listed at the top of this form.*

Contact Information

Affiliation*

Select

What department are you in?*

Select or enter value

Name of Organization Requesting Service*

Contact Name for Requesting Organization*

Contact Email*

Contact Phone Number*

Phone

Is your organization a recognized Live Well San Diego partner?*

Select

Who is your organization's Live Well San Diego partner liaison?

Leave blank if unsure.

Event Information

Event Name*

What is the purpose of this event?*

Are you expecting any media or high-profile guests at the event?*

(local politicians, news stations, etc.)

Yes

Maybe

Please explain what media or high-profile guests you are expecting.*

Please review the service description list to determine which services would be the most beneficial for your event.

What is the main County service your organization would like at the event?*

Please note all services selected below are not guaranteed and are subject to staff availability.

Select

Is there a second County service you would like at your event? (Optional)

Select

What service are you interested in having the Medical Care Services pharmacist provide?*

Please choose the service you are most interested in having.

Health Education

Blood Pressure Screening

Naloxone Distribution and Education

What type of health education are you interested in having at your event?*

Please select the health topic you are most interested in having. If there is a topic that is not listed, please type it in the box below.

Select or enter value

Suggested Services

Are there any additional services or is there a service you don't see on the list above that you think the County could provide? Please leave suggestions in the box below.

Event Location

Name of Location*

Street Address*

Please provide us the address to the event or location where services will be rendered

City*

Zip Code*

Please attach site map.

Please indicate on a map where the bus would preferably be parked. Please note, the bus cannot be parked on a street with through traffic. If you do not have a site map, please provide a Google Map image with the area you would like the bus circled.

Drag and drop files here or

Event Date and Time

Event Date*

Is this a recurring event?

Select

Please provide details of recurrence.

i.e. Every 4th Tuesday

Is this date flexible?*

Select

Event Start Time*

**Note: Regular bus hours are 8AM-5PM.Events outside of these hours will still be considered but are subject to additional approvals.

Event End Time*

Event Set Up Time*

Please indicate the time the bus would need to arrive at the event location. Minimum 30 minute set up time required.

Expected number of community members to be served*

Is there a focus population for this event?

i.e. API Community, students, people experiencing homelessness, etc.

Select

Please provide details about the focus population.

Do you anticipate having language needs other than English at this event?

Select

Please specify what language(s).

Optional: Additional Event Info

How did your organization hear about the Live Well on Wheels?*

Select

If you selected "Other" above please list below how you heard about us*

Send me a copy of my responses

Privacy Notice|Report Abuse

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.