Mobile Health Collaborative Vendor Registration- October 13, 2021                             Neighborhood Recreation Center 
Thank you for joining us on October 6th. You will hear from us within the next few days to confirm. Detailed Instructions will be sent closer to the event.  Thank you. Any questions? contact mariela.perez@unlv.edu 
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Contact first name *
Contact last name
Contact phone number *
Contact email address *
What services will you be providing? *
All services here are free- but do you accept Medicaid for your usual services ? *
Are you able to assist with Medicaid sign up at the event? *
Will you need power? *
Will you need Wi-Fi access? *
Do you have a preference on being placed inside in the gym, inside in a more private location,  or outside (in a mobile vehicle)? *
Can you assist patients in getting to your facility? (Bus passes, Pick up etc.) *
Can you schedule future appointments from the event site? *
Who is your target population? *
Select all that apply
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