Request for Community Event

Requests must be submitted at least 60 days prior to event.

Please note that copies of Virtua Health’s Certificate of Insurance may be available upon request. If your organization requires a signed “Hold Harmless” agreement or similar signed documents for event participation from Virtua Health, a minimum of 45 days advanced notice is required for our signature authorization process.

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Event Point of Contact Information

Please enter your first name
Please enter your last name
Please enter your position/title
Please enter your phone number
Please enter your e-mail

Organization Information

Please enter your organization name
What is your organization type?
Please enter address
Please enter city
Please select state
Please enter zip code

Event Information

Please enter the event name
Please select event type
Please enter a valid date (mm/dd/yyyy)
:
Please select all start time fields
:
Please select all end time fields
Please enter event venue
Please enter event address
Please enter event city
Please select event state
Please enter event zip code
Please select one option
Please select one option
Please enter a valid date (mm/dd/yyyy)
Please enter a number

Requested Programs and Service Lines

If you are inquiring about services that are not listed on this form, kindly highlight those services in the "Additional Information" box so we can connect you with the right resources.

Programs and Service Lines
Please enter additional information
Please enter a file