Event Request Form

Thank you for inviting Georgia SHIP to participate in your upcoming event. We will make every effort to accommodate your request. Allow two weeks of advance notice. We will contact you to confirm the event details.

Event Name (required)

Event Date (required)

Event Start Time (required)

Event End Time (required)

Contact Name (required)

Organization Name (required)

Contact Phone

Contact Email (required)

Confirm email (required)

Estimated number of attendees (required)

(maximum of 500,000)

Event Address (required)

Address 2

City (required)

Zip Code (required)

State

Event County (required)

Event Type

Medicare Presentation

Booth, Exhibit or Health/Senior Fair

Topics

Medicare Basics (Parts A, B, C and D)

Medicare Supplement Insurance (Medigap Policies)

Medicare Preventative Services

Medicare Financial Assistance Programs (Extra Help and Medicare Savings Programs)

Medicare Appeals

Other

(If 'Other' selected, please specify):

Target Audience

Medicare Pre-Enrollees and Beneficiaries

Family Members and Caregivers

Other

(If 'Other' selected, please specify):

Comments:

(Please Note: Do not include your Medicare, Social Security Number or Date of Birth)

Event Request Form

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