Host an Event Form

Comment

GrassrootsEvent

1. * Coordinator Name
2. * Coordinator Address
3. Coordinator Address 2

City, State, Zip*

1. * City
   City
2. * State
   Select An Option Alaska Alabama Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
   State
3. * Zip
   Zip Code

1. * E-mail Address
2. * Phone Number
3. Event Name
4. * Event Location
5. Event Address
6. Event Address Line 2

Event Date / Time*

1. * Event Start Date
   Start
2. * Event Start Time
3. * Event Start AM/PM
   AM/PM AM PM

Event End Date / Time*

1. * Event End Date
   End
2. * Event End Time
3. * Event End AM/PM
   AM/PM AM PM

1. * Event Description
2. Event Website or Facebook page

Is this a public event?

1. Yes

Is this an annual event?

1. Yes

1. * Would you like a PBCC representative present?

   1. Yes
   2. No
2. Upload a photo for the event
3. Upload other files for event: (max. 15MB)

How many PBCC materials do you need for the event? Quantities of material are based on availability at the time we receive your request. If you would like to request additional quantities of any PBCC materials, please email opens in a new windowKristen@PABreastCancer.orgcreate new email or call 717-769-2301.

1. General PBCC Brochures
   Quantity 0 25 50 75
2. Wristbands
   Quantity 0 25 50 75 100 125 150
3. Screening Guidelines
   Quantity 0 25 50 75
4. Nail Files
   Quantity 0 25 50 75 100 125 150
5. Self-exam Cards
   Quantity 0 25 50 75
6. Pink Ribbon Stickers
   Quantity 0 25 50 75 100 125 150
7. Frontline Newsletters
   Quantity 0 25 50
8. Pens
   Quantity 0 10 25 50 75 100 125 150
9. 'We Can Help' Brochures
   Quantity 0 25 50 75
10. Lip Balms
    Quantity 0 25 50 75 100 125 150

Agree to opens in a new windowGuidelines for Grassroots Partnersopens PDF file

1. * I have downloaded, read and understand the PA Breast Cancer Coalition's Guidelines for Grassroots Partners. ( opens in a new windowDownload PDF)

Please check to verify that the event will benefit the PBCC

1. * I've verified that this event will benefit PBCC.

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