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. Organization name* Organization type*BusinessMedicalCommunity/public service agencyResidential communityPlace of worship/faith-based organizationSchoolOther (describe below)Other (specify) Contact person's name* First Last Phone*Email* Have you worked with the UF Health Cancer Center or UF Health before?* Yes (provide details below) No Provide details Is your event open to the general public or limited to members of your organization?* Open to public Limited Date, time, and address of event*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 bus?* 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
