2017 Health & Wellness Fair Booth Registration Please complete this form to register for a booth at the 2017 Health & Wellness Fair no later than Friday, October 13th, 2017. For questions or changes to your form, please contact Kyla Burns at firstname.lastname@example.org or 228-3642 up until October 1st. After October 1st please direct your inquiries to Nick Dirkes at email@example.com or 228-3643. Health & Wellness Fair Saturday, October 28th 8:30 AM - 12:30 PMHealth & Wellness Fair booth setup - Friday, October 20th 7:00 AM - 9:00 PM Organization / Department Name Contact Person Telephone Number E-mail Address Mailing Address Preferred Method of Communication Select One… Phone Email Physical Mailing Which Wellness "Category" do you offer? (may select more than one) Intellectual Spiritual Professional Environmental / Safety Financial Social Physical Emotional We would like to be a part of the Health & Wellness Fair by supplying the following: (ex: types of screenings, services, free offerings, giveaways, information.) Will you require electricity at your booth? (you must supply extension cords) Yes No How many tables will you need? Select One… 1 2 3 How many chairs will you need? Select One… 1 2 3 4 5 6 Please use the following space for any additional comments or requests regarding your booth: List of Registered Booths:Budde Family Dentistry: Activity for kids and information about oral health.FMDH Cardiac Rehabilitation: offering blood pressure checks, body mass index, and cardiac risk factors. FMDH Emergency Medical Services: Ambulance toursFMDH Health Information Management: Info regarding your rights and your health information.FMDH HMS General Surgery: Info on screening colonoscopies and bicycle helmet safetyFMDH Pharmacy: "Ask a Pharmacist" FMDH Surgical Services: offering child identification kits.National Guard: offering blow-up obstacle course outside.Osteo 1 Inc. / Zimmer Biomet: Interactive joints, implants, and trays that are used during surgery.