Event Screening Request

Augusta Health's Community Outreach and Partnerships program connects our community with free health screenings and services.

The Community Outreach and Partnerships program offers free screenings for presentations that are open to the community at large.

Applications must be submitted at least 30 days prior to the event. We attempt to accommodate all requests based on availability of resources.

If you are interested in free health screenings for your event, please complete this form. Presentations for businesses should be requested through Workplace Wellness.

"*" indicates required fields

Contact Information

Requested Organization*

Contact Person*

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Event Details

Event Date*

Start Time*

Length of Event*

Type of Event or Program*

Location*

How many people do you estimate will attend?*

What is the goal of this event or program?*

What population will be served at the event or program?*

How will the event be promoted? **

How will Augusta Health be recognized? **

What health need does this event or program address? **

What services would you like Augusta Health to provide? **

Date a decision is needed*

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Name

This field is for validation purposes and should be left unchanged.