COE event request Thank you for your interest in having us be part of your upcoming event. A member of our team will follow up after receiving your submission. Lead organization name* Event planner name* Phone*Email* Event detailsTitle of event* Event flyerMax. file size: 125 MB.Event descriptionEvent location* Event address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Event date* Set-up time Start time* End time* Is this event open to the public?* Yes No Estimated number of attendees 1-25 26-50 51-100 101-200 201-500 500+ Is it an indoor or outdoor event? Indoor Outdoor Will a table/tent/chairs be provided for our team? Yes No Is registration required? Yes No If yes, provide registration link or registration instructions Audience and language needsTarget audience* General public College and university students Senior groups K-12 students Health professionals Faith-based communities Families Corporate/workplace LGBTQ+ Select all that apply.Preferred language* English Spanish Select all that apply.Requested servicesCheck all that apply. Speaker (provide topic below) Mobile Cancer Screening Connector. Brings cancer screening services directly to communities. Services include 3-D mammography and on-site screenings for cervical and prostate screenings. If selected, additional request fields will populate. Cancer Prevention Services. Offers assistance with scheduling cancer screenings; accessing at-home FIT kits (a stool test to screen for colorectal cancer); and connecting to services for cervical, breast and prostate cancer. Cancer Education. Provides information about cancer risk, early detection, treatment and survivorship across all cancer types. Please select from cancer types below. Community-Engaged Research. Provides information about research, why community participation matters, and shares ways to get involved. Speaker topic Cancer type Brain Breast Colorectal Lung Other Is this a health-focused event? Yes No Does the site have a flat, level, and safe surface for parking, without any overhead obstructions that is safely accessible for patients and staff? Yes No Is the designated space large enough to accommodate the mobile vehicle? Yes No (Overall length = 40’, Height 13’, Exterior width = 102”)Does the site have accessible, appropriate (100 amp) safe, and tested connections (e.g., proofed outlets) and electricity? Yes No These are not required, but we need to plan to run the generator if there is not a plug available.Is the site in a service area with reliable cell phone service connection? Yes No Does the event location have accessible parking and bathrooms for patients and Connector staff? Yes No PromotionCan we share your event on the UF Health Cancer Center's online calendar?* Yes No Can we also include the event organizer’s contact information to allow interested research faculty or staff to connect for potential collaboration or additional details?* Yes No
