Name of Organization (required)

Event Name (required)

Type of Event (required)
(Health fair, donation drive, etc.)

Event Date (required)

Event start time (required HHMM)

Event end time (required HHMM)

Event location (required)

Street address

Apt, Suite, Bldg. (optional)

State/Province/Region/Country

City

Postal/Zip code

Number of People Expected to Attend Event (required)

Event Demographics (required)

Event Contact Name and Title (required)

Event Contact Email (required)

Fetter Health Care Network offers the following services at community events. While we will make every effort to accommodate your requests, please note that Fetter cannot provide all services at one event.

Please check all services requested.
 Blood Pressure Screenings and Information BMI Screenings and Information Health Education Information Only Women's Health - Self Breast Exams and Education; Pap Smear Education HIV Testing and Information Other (please specify in the next question)

Please identify specific needs here. (Please share if no additional needs are requested, required).

Characters left: 250

In about 50 words or less, please summarize your event here.

Characters left: 300

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