Event Requests for Participation Thank you for your interest in Piedmont Health Services. Organizations are welcome to submit requests for Piedmont Health to attend an event. Please fill out the form below as complete as possible. Requests will be reviewed (monthly or bi-weekly) and responded to in a timely manner. If there is any need for additional information Piedmont Health will contact the requesting organization directly. Requesting Organization Name:*Today's Date* Event Description*Please Describe Your EventRequesting Health Screenings Health Talk Food Demo Oral Screenings Other Otherspecify other requestEvent Organizers Contact Name*Organizers Contact Number*Contact Email Address* Event Date* Event Time* : HH MM AM PM Annual Event Yes No If this is an Annual Event, how many years?Event AudienceWho is this event for?Expected Number of AttendeesPlease explain event and benefits to Piedmont HealthAdditional CommentsQuestions?PhoneThis field is for validation purposes and should be left unchanged.