Exhibitor/Screener Form

You are cordially invited to take advantage of the opportunity to be an exhibitor for the Annual Terre Haute Community Health Fair on Sunday, January 29, from 1-4pm at the Hulman Center, Terre Haute, Indiana.

The event is designed to invite leaders of the Terre Haute community to provide health care information to residents of Vigo county and surrounding communities. This event also offers a great opportunity of networking and educational outreach, as well as basic health screening for participants. The health fair has proven to a well received event which is demonstrated by the attendance record.

Booths Include:

Ø  2 chairs

Ø  Trash can

Ø  Electricity (Electrical needs for exhibitors must be determined no later than two weeks prior to the Health Fair for each booth requiring this service.) 

Exhibit Set-up

Exhibitors may begin setting up at noon and are requested to arrive by 12:30pm on Sunday, January 29, 2011. Exhibits may be removed after 4pm.

Submission Deadline and Instructions

Please complete the enclosed application and return by December 7, 2011.  Exhibitors will receive detailed information regarding location, exhibit setup, and day-of details prior to the Health Fair.

Mail or fax to: Indiana University School of Medicine –Terre Haute

                       Landsbaum Center for Health Education

                      1433 N. 6 ½ St.

                      Terre Haute, Indiana 47807

                      Attention: Kristy Nicoson

                       Fax: (812) 237-8128

 Questions?  Contact Anna Grady at awgrady@iupui.edu

 

Exhibitor/Screener Form

8th Annual Community Health Fair

Organized by

  Indiana University School of Medicine –Terre Haute

January 29, 2012

Hulman Center – Terre Haute, Indiana

Please complete and return with the enclosed information sheet.  (Screeners providing medical services will be asked to show proof of insurance.)

Yes, we want to participate in the 2012 Community Health Fair as indicated below:

___ Exhibitor: Topic/Title ____________________________________

___ Screener: Type ________________________________________

# of Tables Requested:  1  or  2

# of Chairs Requested:  1  or  2

# of Exhibitors Expected to be Present: ____

Do you need:

Electrical outlet-    Y       N

Small trash can-     Y       N

Student volunteers to help with the screening/exhibit-        Y         N

         IF YES-- # of student volunteers needed ________

Other requests/information: ________________________________________________________________________

Please provide the following information:

Organization Name _____________________________________________________________________________

Contact Person/Title ____________________________________________________________________________

Street Address _________________________________________________________________________________

City __________________________________          State ______________________        Zip Code _______________

Telephone Number _______________________________        Fax Number _________________________________

Email Address _________________________________________          Web Site _____________________________

Description of organization: _____________________________________________________________________

For additional information, please contact Anna Grady at awgrady@iupui.edu.

Exhibitor/Screener Information Sheet

 Organization Name:________________________________________________

 Please provide the following information for all individuals who will be representing your organization:

Name __________________________     Title ____________________________

Has this person ever been convicted of a felony?  Yes____     No____

Does this person require any special accommodations?*  Yes____     No____

      If yes, please explain ________________________________________________

 

Name __________________________     Title ____________________________

Has this person ever been convicted of a felony?  Yes____     No____

Does this person require any special accommodations?*  Yes____     No____

      If yes, please explain ________________________________________________

 

Name __________________________     Title ____________________________

Has this person ever been convicted of a felony?  Yes____     No____

Does this person require any special accommodations?*  Yes____     No____

      If yes, please explain ________________________________________________

 

Name __________________________     Title ____________________________

Has this person ever been convicted of a felony?  Yes____     No____

Does this person require any special accommodations?*  Yes____     No____

      If yes, please explain ________________________________________________

 Please complete and return by December 7, 2011. 

 Mail or fax to:                                                                                                           

            Indiana University School of Medicine –Terre Haute

            Landsbaum Center for Health Education

            1433 N. 6 ½ St.

            Terre Haute, Indiana 47807

            Attention: Kristy Nicoson

            Fax: (812) 237-8128

 *Regarding the Americans with Disabilities Act of 1990

 

THANK YOU FOR YOUR PARTICIPATION!

 

ĉ
Shaily Patel,
Oct 26, 2011, 3:08 PM
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