Community Conference Space Inquiry Form

(541) 672-9596 Umpqua Community Health Center is now Aviva Health!

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Name *

First

Last

Phone

Email *

Organization Name

Nonprofit Status

Event Name

Event Date and Time

Date

Time

Brief Description of the Event

Estimated Number of Attendees

Status the and

Number of Parking Spaces Needed

Is the Event Open to the Public?

Questions or Comments

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Contact

150 NE Kenneth Ford Drive
Roseburg, Oregon 97470
(mail or serve all legal documents to this address)

(For unsecured communications only. Please submit private medical information and questions through Patient Portal)

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