MSDH Employees Registrations – Healthy MS Conference

MSDH Employee Registration

Join Our Mission for A Healthy MS!

Name *

First

Last

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Credentials (if applicable)

Name as you wish to see it printed on badge

Email *

Phone *

Address *

Address Line 1

City

State

Zip Code

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Registration Type *

Please Select Payment Type: *

Self-Pay (employee paid)
Approved Scholarship/Program Fund Request

*ECHMC is a not-for-profit/non-income event. All funds collected go directly toward conference operational costs. Forms and payments sent by mail must be received by April 15, 2025. Thank you for supporting our mission.

T-Shirt Size *

MSDH Position Title *

Program Name *

Supervisor Name *

Emergency Contact Information

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Name *

Phone *

Conference Cancellation/Change Policy

Cancellation requests must be received in writing on or before May 1, 2025. A refund for conference registrations may be issued minus an administrative fee of $25.00.

However, if you cannot attend, someone from your organization may participate in your place. Cancellation and substitution requests must be submitted and confirmed via email to info@healthymsconference.com

Hotel cancellation policies are at the discretion of the hotel and apply separately.

Agreement *

I have read and accept the above Conference Cancellation/Change policy.

Registrations received without payment will not be processed. *ECHMC is a not-for-profit/non-income event. All funds collected go directly toward conference operational costs. Forms and payments sent by mail must be received by April 15, 2025. Thank you for supporting our mission.

Select Payment Options *

MSDH Employee/Retired - $ 50.00
MSDH Employee - Will pay by Purchase Order - $ 50.00
MSDH Scholarship - $ 0.00
Conference Committee ONLY - $ 0.00

For mailed payments, please make checks Payable to MSDH Office of Preventive Health and mail to the attention of Charlotte Holly, Mississippi State Department of Health, P.O. Box 1700, Jackson, MS 39216-1700

Purchase Order # (if applicable)

Questions? Please email info@healthymsconference.com.

Stripe Credit Card

Card

Name on Card

If you are paying by mail, please select the By Mail payment option above and bypass the Credit Card area. Registration will not be accepted if you select Online payment and do not enter your credit/debit card information. If you have any issues or questions, please email the conference planner at info@healthymsconference.com or call 228-326-0824.

Total

$ 0.00