Group Request Form

Complete this form to request Nurse Educator to come to your location to provide services for group of 4 or more students

* Name
* E-Mail address
* Phone Number
* School
* Program
* Number of Students You may set up groups of 4 or more
* Location Please indicate if you would like to come to the Cambridge or Kitchener location. If you would like to arrange this in your home, please provide us with the full address. Please be aware that this cannot be offered at your school.
* Services Requested What services are you looking for us to provide at your location	Please select Mask Fit Testing
* Date Requested Please select options for dates and times requested	Monday Tuesday Wednsday Thursday Friday Saturday Sunday Morning 8:00am-12:00pm Afternoon 12:00-4:00pm Evening 4:00-8:00pm
Specific Dates If you have a specific list of dates that work best for your group, please enter that information here.