Student 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

Name of College or University (currently attending) *

Degree/Field of Study *

Expected Graduation Date *

Emergency Contact Information

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Name *

Phone *

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Registration Type *

If paying By Mail - please print and send this form along with payment to Mississippi State Department of Health, Office of Preventive Health, C/O Charlotte Holly P.O. Box 1700, Jackson, MS 39216. Forms and payments sent by mail must be received by April 15, 2025. Thank you for supporting our mission.

Please Select Payment Type *

Self-Pay (student paid)
Approved Scholarship 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 *

Conference Cancellation/Change Policy

No refunds will be provided for student registrations. However, if you cannot attend, someone from your organization/school may participate in your place. 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 Conference Cancellation/Change policy above.

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.

Questions? Please email info@healthymsconference.com.

Stripe Credit Card

Card

Name on Card

Student Registration - $25.00. If you are paying by mail, please select the By Mail registration type and bypass the Credit Card area above. 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.