PECaD Event Participation Request Form
Thank you for your interest in having PECaD attend your event. Please complete the form below, and one of our team members will be in touch soon.
Organization Name
*
Organization Contact
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Requested Screening Event Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Requested Event Hours
(e.g., 9:00 a.m.–1:00 p.m.)
To help us prepare for your event, and provide an excellent experience for your attendees, please let us know services you are requesting
*
Community outreach and screening education
Colon cancer screening
Prostate cancer screening
Inflatable colon
All of the above
Other
To help us prepare for your event, and provide an excellent experience for your attendees, please let us know if you anticipate a large percentage of any of attendees who:
*
Speak English as a second language
Are uninsured or underinsured
All of the above
Is this request for a special event? (Health fair, 5K, etc.)
*
Yes
No
Submit
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