Connector event request If you are an organization seeking to request the Mobile Cancer Screening Connector at an upcoming event, please complete this form and a staff member will get back to you. Contact InformationOrganization name* Contact person's name* First Last Phone*Email* How did you hear about the Mobile Cancer Screening Connector?* Event DetailsEvent name* Type of event* Health-focused fair Community gathering Sporting event Professional event Other (specify below) Specify other type of event Date requested* Date is flexible* Yes No Time requested* Please list the time the Connector can arrive to set up, what time the event opens to the public, and approximately when the event ends.Expected number of attendees* Location informationWhen choosing a location for your event, please be mindful of the dimensions of the Connector (40’ long, 13’ high, and 102” wide). If you have any questions or concerns about the size of the vehicle, this can be discussed further during your phone consult with our staff. Event location (address and detailed description)* Accessibility details: Are there any specific accessibility needs or concerns?* If no, please enter N/AParking availability: Please provide a photo of the desired location of the ConnectorMax. file size: 125 MB.Are permits/other approvals from local authorities required for the Connector to be present at this location?* If no, please give N/AOn-board ServicesPlease check all services requested and we will confirm availability* Select All Wellness and risk reduction resources (e.g., tobacco cessation, nutrition) Mammography (for breast cancer) PSA screening (for prostate cancer) Pap smear (for cervical cancer) FIT test distribution (for colorectal cancer screening) Cancer education (general prevention, screening and other guidance for a variety of cancers) Research study education and enrollment opportunities
