If paying by check you will be redirected to a download page where you can print out the Registration Form, fill-out, and return via fax or mail. Check *you will be redirected and any unsaved changes will be lost
Online Registration
Please make sure you complete each field accurately to prevent incorrect information and to ensure quick processing. Name Prefix (Dr., Mr., Mrs., etc.) First and Last Name: *required Degree(s) Specialty/Discipline Organization Address Address Line 1 *required Address Line 2 City *required Zip/Postal Code *required State AL AK AS AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RH SC SD TN TX UT VT VI WA WV WI WY Non-U.S. *required Country *required Phone Office ext. Fax *required Email *required Please answer the following survey questions. 1. How did you learn of this meeting? 2. Do you want your contact information to be included in the Participant Roster? Yes No 3. Please Specify any Dietary Requests The conference registration fee includes one program book and daily continental breakfast, lunch and coffee breaks. *required Conference (November 6 & November 7) 1. Registration $150 Individual Pre-Conference or Post-Conference: 3. Pre-Conference Workshop I: HIV/AIDS (November 5) $75 4. Pre-Conference Workshop II: Domestic Violence (November 5) $75 5. Post-Conference Workshop I: Mental Health (November 7) $75 6. Post-Conference Workshop II: Cancer (November 8) $75 7. Conference Package (Conference + 4 Workshops) $350 8. Gala Dinner and Reception (November 6) $75 Payments must be made in US dollars via credit card (VISA or Mastercard) or Check. Your card will be billed by ACCESS Community Health & Research Center. *required To complete your registration, you must Pay on Line by Credit Card. After Submitting Form you will be relocated to a Secure Form. Please note once you click submit, this signifies that your completed registration form has been received. However, registration is not finalized until a payment has been made. If you are completing an entitled registration, click submit and disregard the payment page.
Registration
Individual Pre-Conference or Post-Conference:
Payments must be made in US dollars via credit card (VISA or Mastercard) or Check. Your card will be billed by ACCESS Community Health & Research Center. *required
To complete your registration, you must Pay on Line by Credit Card. After Submitting Form you will be relocated to a Secure Form.
Please note once you click submit, this signifies that your completed registration form has been received. However, registration is not finalized until a payment has been made. If you are completing an entitled registration, click submit and disregard the payment page.
