SWWI Health Fair/Community Event In-take Form

SWWI Health Fair/Community Event In-take Form

Please fill out the information below to request a Mayo Clinic Health System (MCHS) expert to be present at your upcoming health fair or event. We ask that you submit your request at least six weeks in advance. This is not a guarantee that someone will be able to attend.

If you have any questions please contact the SWWI Community Engagement at LAComEng@mayo.edu.

Today's Date

Title of Fair/Event:*

Location & City:*

Date of Fair/Event:*

Time:*

Contact Name*

Contact Phone Number:*

Contact Email Address:*

Who do you expect to attend the event? (Consider: age, gender, type of work, etc.)*

Number of people expected to attend:*

Is the event open to the public? (Check the box if yes.)

Is there a cost to attend the event? (Check the box if yes.)

What is the format of the event? (Consider: # of booths, setting, is there a speaker, what is the goal of the event?)*

Will other healthcare organizatons be present? If so, what is their role?*

How much space is there for display? What will be provided (table, etc.)?*

What is the cost of display space?*

Has MCHS participated in this event before? If so, please briefly explain our participation*

What would you like MCHS to provide (speaker, booth, health screening, information, etc.)?*

What topic(s) would you like MCHS to cover?*

Reply Deadline*

Please attach any other information you would like to add.

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