Community Event Request

Agency / Business / Event* - required

Requester's Name:* - required

Phone #:* - required

Email Address:* - required

Agency / Business / Event Website Address:

Event Date: (Request at least 30 days in advance for consideration)* - required

Start Time:

End Time:

Description / Details:* - required

Location and Address:

Location Set-Up: (indoors / outdoors, tables, etc)

Services Requested:

Staff:

Clinical Non-Clinical Both maximum 1 allowed

Targeted Audience:

Demographics / (#attendees, age, etc.):

Sponsorship:

Upload Supplementary Information:

You have entered an invalid code

Refresh Get Audio Code

Type the code from the image

Mandatory field(s) marked with *

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number H80CS25684 for Health Center Cluster in the award amount of $7,278,563. Of the total project, 86.4% is financed with nongovernmental sources. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.

The C. L. Brumback Primary Care Clinics were granted Federal Tort Claims Act (FTCA) deeming status effective January 1, 2024.

Top