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Mobile Mammography Inquiry
Please complete the survey.
1.
Contact information
Full name:
Phone number:
Email address:
2.
Second point of contact
Full name:
Phone number:
Email address:
3.
General event information
Name of event:
Name of organization:
4.
Event details:
Date of event:
Event time frame:
Event location:
Event confirmation needed by:
5.
Type of event ( Check all that apply)
Corporate event- Open to all company employees
Community event- Open to the Community and Public
Private-not open to the public
6.
Additional details
Will your organization require a Memorandum of Understanding (MOU)for this event/partnership?
Will mammograms be paid for by the organization?
Is there a property management company involved with the event location?
Will there be media coverage or elected officials at this event, if so please specify?
7.
Are the participants 40 years old or older?
Yes
No
Not Sure
8.
What type of insurance coverage will participants have for this event? For Corporate partners, please list insurance carrier offered to employees.
9.
What is the goal for this event?
10.
Special instructions, requests, or additional comments.
11.
How did you hear about our services?
Website
Social media
Event or health fair
Organization
Other:
