Wellness on Wheels (WOW)
Mobile Health Unit - Request Form
Thank you for your interest in having Wellness on Wheels at your event. Please complete the following form, and a team member will contact you. * Events must be requested at least 30days before the event day.
1. Contact Information
Name of Company or Organization
*
Contact Name (first and last)
*
Title
Phone Number
*
Email Address
*
2. Event Details
Title of Event
*
Date (mm-dd-yy)
*
Event Location
*
Event Address
*
Vendor Setup Time
*
Event Start Time
*
Event End Time
*
3. Event Questions
What services are you requesting the W.O.W provide?
*
Vaccines for Children
STI/STD testing
Lead testing
Blood Pressure Screenings
Narcan/STB Training
Other (if other please fill in the blank below)
If other was selected, please fill in the blank:
Please describe your event
*
Have you held this event before?
*
Yes
No
Does your event have a target audience?
*
How many attendees are you expecting?
*
Will there be any other Mobile Units attending this event?
*
Yes
No
If needed, will your facility be available for use (restrooms, etc)?
*
Yes
No
Can 5 parking spaces be reserved to accommodate the mobile unit (33'L x 8'W x 12.8'H)?
*
Yes
No
Are staff available for a site visit (3 weeks before the event)?
*
Yes
No
If Yes, please fill in the blank with availability dates and times.
*
Is electricity available for the Mobile Unit to use during the event?
*
Yes
No
Attach Event Flyer:
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