Community Van Location Request
Thank you for your interest in hosting a screening event with the Siteman Community Van. Our mobile screening unit travels throughout the St. Louis region and surrounding communities, providing cancer screenings to all eligible individuals, regardless of insurance or income. After you submit the form below, a member of our team will contact you to discuss your request and next steps.
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
Date
Requested Event Hours
(e.g., 9:00 a.m.–1:00 p.m.)
Will our staff be able to access indoor bathrooms during the screening day?
*
Yes
No
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 attendees who speak English as second language:
*
Yes
No
Is this request for a special event? (Health fair, 5K, etc.)
*
Yes
No
Does the location have a flat and level surface for parking (such as a parking lot or street)?
*
Yes
No
If the location requires a parking permit from the city, you may be expected to take additional steps to ensure parking for the day/event. Does the location require a parking permit?
*
Yes
No
Unknown
Submit
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