CCC_SimpleSend_OurImpact_CommunityOutreach

Community Event Request
Contact Information
First Name*
Last Name*
Email*
Name of Organization making request*
Address of organization making request*
Brief description of the organization

0/1000
What role do you hold at this organization
Please describe your role:
Event Details
Event Name*
Event Date - Start*

MonthDayYear
Date
Event Date - End*

MonthDayYear
Date
Event Time - Start*
*Specify the start and end time for the event day. If the hours vary for a multi-day event, specify the earliest and latest hours for the event days overall.
Event Time - End*
Event Location*

Street Address

Street Address Line 2

CityState

Zip Code
County in which Event taking place*
What type of an event is it?*
Does your event have a specific health focus? Check all that apply.*

Breast HealthColorectal HealthSkin Health/Skin CancerProstate HealthCancer geneticsSmoking Cessation/Lung HealthNutrition and Eating WellMen’s HealthWomen’s HealthCancer Prevention/ScreeningsCaregiver SupportSurvivorshipOther
Is your event a fundraiser?*
Check here if you are interested in making your event a fundraiser that supports The James. A team member from The James will contact you to discuss further.
Is your event a fundraiser?*

YesNo
Who/what is the benefactor of the event?
How many people are expected to attend the event?*

0-100101-250250+
What is the primary audience for this event? Check all that apply.*

Family Event (children and adults)Adults (18+)Adults (55 & older)Women/Female IdentifyingMen/Male IdentifyingChildren/Youth (under 18)Other
What type of support would you like to receive for your event? Check all that apply.*

Educational LiteraturePromotional GiveawaysEvent Table with an OSUCCC-James representativeMobile UnitOther
Mobile Unit (check all that you are interested in)

Community Care CoachMobile Mammography UnitMobile Lung Screening CoachMobile Education KitchenOther
page_url
gclid
Sender Name
Enter the sender name for any emails your form sends
Sender Name - Scheduler Email
This will be the sender name for the scheduler. The title of the form is helpful. Example: Appointment Request: Orthopedics
Should be Empty:

Community Event Request

Contact Information

Event Details