Thank you for your interest in partnering with the Froedtert & the Medical College of Wisconsin health network to provide community-based health screenings and education. We seek opportunities that align with our health network’s Mission and Values and support our efforts to address community health needs through innovative programs and partnerships that improve population health and reduce disparities.Due to the large number of proposals we receive, ALL requests must be submitted through the online request form at least 60 days prior to your response/print deadline date and event date. As much as we would like to support every organization, concentrated consideration is given to programming/event requests that:Aim to improve access to health care services.Advance medical or health care knowledge.Enhance the health and wellness of the communities we serve.After submitting your request, you will receive a confirmation e-mail that includes a copy of your responses. Please keep in mind that the Froedtert & MCW health network does not provide community resources to support:Requests that benefit an individualPolitical campaigns and elected officialsFundraising initiatives incompatible with our health system foundationsRequests may be approved, denied or partially fulfilled based on alignment with strategic needs, current events and staffing or resource availability. You will receive a response within two weeks after submitting your request.Please click here to submit a charitable giving and sponsorship request. These include nonprofit fundraising events.Please click here if you are looking for information about Workforce Health, such as employer requests. Qualifying Date NOTICE: Your event date must be on or after 06/26/2024 to be considered for this submission. Event Start Date and Time Event Start Date and Time: Date Event Start Date and Time: Time All requests must be submitted at least 60 days prior to your response/print deadline date and event date. Event End Date and Time Event End Date and Time: Date Event End Date and Time: Time Is your event less than 60 days away? Yes No STOP You cannot request Froedtert & MCW participation less than 60 days before the event. Set-Up Time Please include the time when we may arrive to set up. Name of Organization Official Name of Event/Opportunity Are you applying for multiple events with this request? Yes No Please list other dates and names of events. Requesting Organization Description Mission of Organization Organization Contact Main Phone Address Address 2 City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Organization Website Service Area of Organization Fond du Lac County Manitowoc County Milwaukee County Ozaukee County Sheboygan County Washington County Waukesha County Other… Enter other… Please choose all that apply. Event Overview Is there a cost to Froedtert & MCW health network to participate in the event? Yes No Event Participation Fee Event Description Please limit to 200 words. Event Location Event Location Name Event Location Address City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code What is the goal of the program or event? Please limit to 200 words. Audience Size - Select -0-5051-150151-300301-500501-750751-10001000+ How long has the event been in existence? - None -Less than one year1-2 years3-5 years6-10 yearsMore than 10 years How often does the event occur? How often does the event occur? - None -One timeQuarterlyAnnuallyOther… Enter other… What population does this event serve? Youth Racial/Ethnic Diverse Populations Uninsured/Underinsured LGBTQ Seniors/Older Adults Families Military/Veterans General Population Homeless Low Income Disability Other… Enter other… Please choose all that apply. Do you need materials in languages other than English? Yes No Which languages do you need materials in? Event Focus or Topic Areas Behavioral Health Cancer Center Chronic Disease Prevention (blood pressure and blood glucose screenings) Diabetes Nutrition Diversity and Inclusion General Marketing Heart and Vascular Infection Prevention and Control Neuroscience and Stroke Pharmacy Screenings Trauma and Injury Prevention Vaccines Please choose no more than TWO. What cancer materials are you requesting for the event? Breast cancer education Colorectal cancer education Lung cancer education Prostate cancer education Pig lung demonstration/display Strollin' Colon display Other… Enter other… Please indicate the screenings you are interested in. Has Froedtert & MCW health network participated in this event in the past? Yes No If yes, when and for how many years? Please limit to 200 words. Are there any other presenters or sponsors for this event? Yes No If yes, name the other organizations. Please limit to 200 words. Please upload the event flyer (if available). Upload One file only.256 MB limit.Allowed types: pdf, doc, docx. There will be a slight delay while your file is scanned for potential viruses. Please do not refresh or click the back button. Primary Contact Information This is the person who will coordinate the specifics of the program or event. Primary Contact Information Name E-Mail Direct Phone Job Title Please list any additional e-mail address we should copy on responses. Were you referred to this application by a Froedtert & MCW staff member? Yes No Name of Referring Froedtert & MCW Staff Member Requests may be approved, denied, or partially fulfilled based on alignment with strategic needs, current events and staffing / resource availability. You will receive a response within two weeks after submitting your request. 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