Community Outreach Service/Partnership Request You must have JavaScript enabled to use this form. Thank you for your interest in partnering with the Ohio State College of Dentistry. To help us evaluate and coordinate your request, please complete the form below as thoroughly as possible. Requestor information Name of requestor (Required) Phone Number Email Address (Required) Position Affiliation Organization, School, Agency, etc. Organization Type Private Practice / Company Non-profit Government Agency Other… Other organization type Type of Request Request Type One-time service Recurring service Other… Other request type Recurring service visits per year If requesting a recurring service, please specify how many visits per year. Which Service(s) are you requesting? (Check all that apply) Oral Health Information (OHI) Only Dental Screening, Fluoride Treatment, and OHI Mobile Dental H.O.M.E. Coach Provides comprehensive dental treatment by dental students on the mobile dental clinic. The OHIO Project Offers an opportunity for future partners—such as clinics or programs serving underserved communities—to host dental students as part of their clinical training experience. Other… Other service requested Event/Service Information Title of Event (if applicable) Date of Event (if known) (Required) Time of Event (if known) Event Location (address or venue name) (Required) Purpose of event (Required) Please provide a brief description of the event or request. Who is the intended audience for this event? (Required) (e.g., children, seniors, low-income families, students, etc) How many participants are expected per visit? Why are you requesting our service? (Required) Please describe the community need or goal. Additional Notes or Special Considerations (Required) Please let us know about any logistical needs, parking arrangements, or additional support required.