Elementor #1867 – Healthy MS Conference

Registration Form

Name *

First

Last

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Credentials

Name as if you like to see on the Badge.

Company Name

Address *

Address Line 1

City

State

Zip Code

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Email *

T-Shirt Size

Phone *

Registration Type *

Student Registration

We want to welcome students to the Empowering Communities for a Healthy Mississippi Conference and encourage programs to take full advantage of the discount we are providing for students.

Name of College/University currently attending

Student Registration Only

Degree

Student Application Only

Expected Date of Graduation

Student Application Only

STUDENT Application: What are your plans for utilizing the conference information to address health in Mississippi?

Student Application Only

Emergency Contact Information

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Name *

Phone *

Conference and Pre-/Post-Conference Course Cancellations and Changes

Cancellation requests must be received in writing on or before March April 1, 2023. For conference registrations, a refund will be issued minus an administrative fee of $25.00. Substitution requests must be submitted in writing.

Agreement *

I have read and understand the above Pre-Conference and Conference Cancellations/Changes policy.

Registrations received without payment will not be processed.

Questions? Call (877) 673-2462 or email info@healthymsconference.com or healthymsconference@gmail.com

Conference Scholarships Available

If you are having a financial hardship, and would like to attend the conference, please complete the registration form and check Scholarship for payment options. We will reach out to you to discuss further details.

Early Bird Payment Options *

Regular Registration - $ 50.00
Student Registration - $ 25.00
Scholarship Request - $ 0.00

Scholarships will be reviewed within 7 days.

Stripe Credit Card

Card

Name on Card

Total

$ 0.00