Event Vendor Registration Is Now Open

Please select a health fair that you like to register:*

1st Baby Shower (Pine Bluff) - June 25, 2022 | 12pm – 4pm Ambetter Health Fair (Holiday Inn Little Rock Airport Conference Center) July 23rd, 2022 | 10am – 2pm

Name of Organization *

Organization Type

Contact Name *

Position

Phone

Email *

Alternate Contact Name

Phone

Address

City

State

Zip Code

Briefly describe your booth or display:

What type of health screenings or other services will your booth provide?

Equipment

AHW will provide each vendor with 2 chairs. Do you need additional chairs?

Yes No

Number of additional chairs needed:

AHW will provide you with one six-foot table. Do you need additional tables?

Yes No

Number of additional tables needed:

Do you need electricity? (Arkansas Health and Wellness will not be supplying extension cords or power strips. If needed, you must bring your own.)

Yes No

Do you need extra space?

Yes No

If so, please specify what the need is for and how much space is needed:

Will you provide screenings that require a private room?

Yes No

Provide any additional information on screenings:

Will you provide an item for our raffle?

Yes No

Will you stay during the entire event?

Yes No