Community Event Request Form

Maryland Physicians Care (MPC) supports several community-based health events around the state of Maryland that align with our mission statement, vision, and core values. To help streamline requests, we ask that you please submit community event requests using the form below.

Questions?

Contact Shannon Jones, MPC Community Engagement Manager
410-412-9730 | sjones@mpcmedicaid.com

Please submit the below form accurately to be considered.

Requestor Information
Name*
First Last
Email*
Phone*
Event Information
Event / Organization Name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Event Date*
MM slash DD slash YYYY
Event Time*

: HH

MM

AM/PM
County or Area Served*
Website URL*
Facebook Page*
Expected Event Attendance*
Cost to Attend ($)*
Participant Confirmation Deadline*
MM slash DD slash YYYY
How many years has your organization been hosting the event?*
What is the goal of the event?*
How is the event being promoted? Please list all initiatives.*
Events must use the new MPC logo which will be supplied upon approval of event.
What recognition will MPC receive as an event participant?*
Phone
This field is for validation purposes and should be left unchanged.

Community Event Request Form

Questions?

Requestor Information

Event Information