Event Request Form

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Event Request Form

If your group or association would like to invite Unity Health Care to speak or to participate in an upcoming health fair or community event, please complete the below form.

Note: All requests need to be submitted no later than 60 days prior to event. Once received, we will review your application for approval. Application acceptance is based on availability of Unity's resources. Completing this form does not guarantee Unity Health Care's participation or attendance at your event.

Email *

Please check the box that best describes the event host:
*

Individual

Business

School

Non-Profit Organization

Other:

EVENT DESCRIPTION

Name of Event
*

Nature of Event (please explain in detail)
*

Has this event been done before?
*

Yes

Complete address of event site
*

What is the nearest Unity location to event site
*

Anacostia Health Center (1500 Galen Street SE, Washington, DC 20020)

Brentwood Health Center (1251-B Saratoga Ave NE, Washington, DC 20018)

Columbia Road Health Services (1660 Columbia Road NW, Washington, DC 20009)

East of the River Health Center (4414 Benning Road NE, Washington, DC 20019)

Minnesota Avenue Health Center (3946 Minnesota Avenue NE, Washington, DC 20019)

Parkside Health Center (765 Kenilworth Terrace NE, Washington, DC 20019)

Southwest Health Center (850 Delaware Avenue SW, Suite B, Washington, DC 20024)

Stanton Road Health Center (3240 Stanton Road SE, Washington, DC 20020)

Upper Cardozo Health Center (3020 14th Street NW, Washington, DC 20009)

Date(s) of event (ie, Saturday, January 1, 2023)
*

Is the event indoors or outdoors
*

Indoors

Outdoors

If outdoors, is it rain or shine?

Yes

Clear selection

Event time (start/end)
*

Set-up time (start/end)
*

Set-up/unloading procedures
*

Number of expected attendees
*

Is there a cost to participate?
*

Yes

Is there parking for exhibitors/vendors?
*

Yes

If parking is available, where?

Will you provide tables and chairs?
*

Yes

What other organizations are participating? (please list all)
*

EVENT CONTACT INFORMATION

Name of Business/Group/Organization
*

Website (if applicable)

Address
*

Contact Person
*

Contact Person Cell Phone
*

Contact Person Email
*

Alternate Contact Person

Alternate Contact Cell Phone

Unity Health Care has the following services based on staff availability. Please select the service(s) you would like to have at your event (no more than 2 requests).
*

Blood Pressure Checks

Diabetes Screenings

Insurance Enrollment

Provide information Family Planning

Provide information about HIV

Required

Do you already have a strategy to provide follow ups or referrals to people that are found to be in need of medical care?
*

Yes

Who is your target audience?
*

Will you have children at your event?
*

Yes

If you will have children at your event, what are the age ranges?
*

Language(s) spoken by target audience
*

A copy of your responses will be emailed to the address you provided.

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