GBPCA SNPD Registration


	515 West Fourth Street, Carson City, NV 89703 Phone: 775 887-0417 Fax: 775 887-3562 email: healthcare@gbpca.org

Organization/Agency Registration

Safety Net Provider Days for the 75th Session of the Nevada State Legislature
February 17th & 18th, 2009

	Kick-Off PreDay: Monday, February 16^th Appointment schedules and information packets will be sent via email (fax upon request) with a special link to each individual participant's assignments.
	Day One: Tuesday, February 17^th:Nevada Legislature - Room 3100, 401 South Carson, Carson City, NV 89701The day will begin at 8:00 AM (unless you are scheduled for an earlier meeting) for team meetings, appointment schedules, and a review of packets and other information. Midday lunch buffet will be provided by the culinary experts from Fandangos. The days appointments should be completed by 4:30.
	Day Two: Wednesday, February 18^th: Nevada Legislature - Room TBD, 401 South Carson, Carson City, NV 89701 This day will begin around 9:00 AM (unless you are scheduled for an earlier meeting) to participate in meetings that were not able to be scheduled in Day One.

Please register your organization/agency for participation in Safety Net Provider Days:

Organization/Agency Name	Address	City/State/Zip
Registering Representative	Position	Email
Phone	Fax	Cell

Participation requires either an active membership in Great Basin Primary Care Association or sponsorship by an active member.
If you are not a member, please select New Applicant or Requesting Sponsorship. Information on becoming a member can be found at http://www.gbpca.org/join.htm

Participant Status:

Member of GBPCA
New Applicant for Membership
Requesting Sponsorship (Non-Member)

Please provide the following information for all advocate representatives attending for your organization.
Be sure to inform us of any changes, deletions or additions by January 31, 2009. Please list yourself in position # 1*.

Title

First Name

Last Name

Phone
(if different)

Fax
(if different)

Available
Feb.17th

Available Feb.18th

*1.

We encourage your team to have as many advocates as possible.
Should you need more space please continue your list via email or fax directly to Misty Levis at the contact information below..

The following list is optional Information you may provide by indicating the Districts in which your organization is most interested.
You may choose multiple selections.

Comments or questions:

If you have any questions or need assistance with any issues that arise please contact
Misty Levis mlevis@gbpca.org
775-887-0417 Ext 112