Request UVA Participation at an Event

We work with local organizations on community events and health fairs as part of our commitment to partner to improve community health and well-being. Our focus is on participation within the greater Charlottesville area (Charlottesville city, Albemarle, Fluvanna, Greene, Louisa and Nelson counties).

To request UVA Health participation at your organization’s event, please complete this form. For more information, please email the Community Partnerships team or call us at 434.924.2946.

Guidelines for Requesting UVA Participation at Your Event

This form must be completed for all community events.
Requests must be made at least four (4) weeks before the event.
UVA Health participation is based on staff/volunteer availability. UVA attendance is not guaranteed.
Please allow up to five (5) business days for a response. When a decision has been made, a UVA representative will contact you to settle the details.

Community Event and Health Fair Request Form

What type of event are you interested in?

Health Fair

Speaker

Tell us about the event and the type of health screening and health education you would like us to provide:

Requester Information

Requesting organization:

Requester name:

Phone:

Email:

Event Information

Event name:

Type of event:

Provide a brief description of the event and goals.

Event location:

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Date of event:

Event start time:

Event end time:

What time will you begin setting up for the event?

Number of people expected to attend:

Target audience for the event:

Please include as much information as possible about the target audience for your event.

Will there be other vendors at the event?

Yes

No

Please list other vendors you know will be at the event.

Brief description of event and goals:

Tell us about your event. Will you have breakout presentations? What other vendors will be there? Will you include entertainment? Do you use a passport system? Please provide us with the details of your plan.

What health needs does this event address?

How will this event be promoted?

Is this event indoors or outdoors? (Check one)

Indoors

Outdoors

What is your plan in the event the weather does not allow you to have your event outside?

Items provided at event:

Table

Chairs

Canopy/tent

Electricity

Other…

You can check more than one item. You can also choose "other" and fill in the information.

Health screenings requested:

None

Blood Pressure

Mammography

Oral Cancer Screenings

Stroke Risk Assessment

Vision Screening

Varicose Vein/Spider Vein Screening

Peripheral Artery Disease (PAD) Screening

Other…

You can choose more than one option. Choose "Other" if you do not see the option you are looking for in this list.

Is there any special equipment that you may need for the event?

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

No

Please describe your followup or referral strategy.

Do you have an exit survey to record the needs, experiences and opinions of the attendees about this event and future events?

Yes

No

Have you worked with a specific person at UVA for this event in the past, or is there a specific person at UVA you would like to work with?

Yes

No

Enter the name and contact information of the person at UVA you have worked with in the past:

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