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Health Information Provider Table
Health Screening Provider Form

We would like to invite your organization to partcipate in the 2nd Minority Male Health & Wellness Summit. 

Each organization will be provided with a 6-foot table and 2 chairs. If you should need additional exhibit space, please let us know in advance so we can make the necessary arrangements with the facility.  You will need to set up your exhibit between 7:30am and 8:30am.  We are asking that all providers be set up and ready at least 30 minutes before the event begins.

Please complete the provider from below no later than August 1st.  You will receive a confirmation letter to confirm final arrangements.

We look forward to your continued support and thank you in advance for your commitment to men's health.  If you have any questions or concerns please feel free to contact Shelley Johnson.
Email address:sjohnson@lincoln.edu

Please bring:
       -ANY and ALL medical supplies needed to perform the health screenings. 
         We will not be able to provide any medical supplies.
       -Something to dispose any materials that will be used.
       

***Please complete a separate form for each individual screening type***
All fields required

* Required fields
Name *
E-mail Address *
Organization *
Street Address *
City *
State *
Zip *
Phone *
Fax
I will provide the following information/ screening(s), please list:
I will need the follwing number of display tables *
I will need the following (please specify)
The following number of people will attend from my agency: *

I have read and agree to the Privacy Policy *

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