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Community Health Request Form

Thank you for your interest in our community health services. If you have questions about scheduling an event, please contact the Center for Health Promotion and Disease Prevention at (313) 874-3095.

*Asterisk indicates required field.

Today's date Name of requestor Title Phone Number Email Name of organization Do you have a 501(c)(3) on file? These services are for "non-profit" organizations. Referred by:

Event information

Desired date of event (please note that we require 4 weeks' notice) Desired time of event (indicate start and end times) Number of expected participants: Location of event (provide full address) Theme/focus of event: Do attendees have to pay a registration/entrance fee? Audience age range: Who will attend this event? Is this event targeted towards a specific racial or ethnic group? Please specify the language of those in attendance: Please specify the ethnicity of those in attendance: Will there be other health screening vendors at the event? If so, what type of screenings are these other vendors providing? Will you be able to provide tables, chairs and extension cords to our staff? Will you be able to locate our staff close to an electrical outlet? Will the event be located indoors or outdoors? If the event will be located outside, will you be able to provide a tent for our staff to use? If the event will be located outside, is there a severe weather contingency plan in place? If so, please share what the plan is: Please provide a brief description of the space and accommodations:

Community Health Services Request

Please note: Participants must be 18+ years old

Check all that apply Blood pressure and body mass index and tobacco use screening Health literature or education materials Presentation or speaker Presentation topic:

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Community Health Request Form

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