Mom & Baby Mobile Health Center®

Event Request Form

Thank you for your interest in hosting the Mom & Baby Mobile Health Center® at your community event! Please fill out the following form to provide us with more information about your event. This will help us assess the feasibility of attending and ensure that we can meet your needs effectively. We look forward to collaborating with you to promote maternal infant health and wellness in our community!

Organization Information:

Organization Name:

Contact Person:

Position:

Email:

Phone Number:

Address

Address 2

City/Town

ZIP/Postal Code

Event Details:

Event Name:

Event Date:

Event Start Time:

Event End Time:

Event Venue Name:

Address

Address 2

City/Town

ZIP/Postal Code

Expected Number of Attendees:

Mom & Baby Mobile Health Center Requirements:

Requested Date for Mobile Health Center's Presence:

Requested Start Time for Mobile Health Center's Presence:

Requested End Time for Mobile Health Center's Presence:

Purpose of Mobile Health Center's Involvement: (check boxes)

Health Checkups

Prenatal and postpartum care

Newborn care

Reproductive healthcare

General pediatric and adult healthcare

Specialized screenings (hypertension, STI)

Other…

Educational Workshops and Distribution of Educational Resources

Subject Matter:

Other (please specify):

Logistical Details:

Available Space for Mobile Health Center Setup:

Access to Electricity/Water:

Parking Arrangements:

Additional Requests/Comments:

Special Accommodations Needed (please specify)

Other Requests (please specify):

Agreement Terms:

We understand and agree to provide logistical support for the Mom & Baby Mobile Health Center®.

We acknowledge that any requested services are subject to availability.

Submitter's Name and Position:

Name:

Position: