UTHSC Event/Service Request Form

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Thank you for your interest in working with UTHSC to improve our communities. Please use the form below to request community or volunteer services. If you have any additional questions or need assistance with this form, please call the Office of Health Disparities Education and Community Engagement at 901.448.3415 or [email protected]. Please note that we receive more requests than we can fulfill. Submitting this form is not a guarantee of services. Please allow 48 business hours for a response to your request.

Date of Proposed Event

Event Location

Location Name

Address

Zip Code

Event/Agency/Organization Host Name

Target Audience (ages, language, at-risk populations)

Estimated Number of Attendees

Services Requested

Financial Sponsorship

Cholesterol Screenings

Blood Pressure Screenings

Glucose Screenings

Body Mass Index

Dental Screenings

Health Education

Other

Contact Information

First Name

Last Name

Phone

Email Address

Any additional information