AmeriHealth Caritas Ohio Mobile Wellness and Opportunity Center Partner Request Form Survey

Thank you for contacting us for a partnership opportunity with our Wellness Center Program, we are excited to connect with you! Our Mobile Wellness and Opportunity Center is available to all 88 counties within the state of Ohio and is available for events each month between the 1st-15th. Please complete the following form, and we will then pass your information on to the appropriate AmeriHealth Caritas Ohio Coordinator of Community Programs within your region. They will contact you to set up time to discuss how we can establish a partnership and coordinate events. Thank you again for reaching out, and we look forward to building a strong partnership to serve the community together!

1.Contact Information

Name

Company Name

Address

Address 2

City/Town

State/Province

Email Address

Phone Number

2.What type of partnership are you interested in?

Bright Start (maternal and infant health)

Ready to Learn (child health)

Wellness In Reach (health and wellness for all ages)

Other (please specify)

3.How did you hear about our program? (Please be as detailed as possible: Date, Name of Event, or AmeriHealth Associate name, etc.)

4.What county is your organization located in?

5.Do you have adequate space to park the bus? (44’x18’)

6.What type(s) of events are you interested in hosting the bus?

7.Please list potential event date(s)

8.What is the anticipated number of event attendees?

9.Any additional information/comments?

Thank you for your interest. We will review your information and reach out to discuss a partnership!