Registration and Membership in NC Swimming and USA Swimming.
Annual Conference Registration/Membership Form B CONFERENCE REGISTRATION Registration...
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Name: ________________________________ Email address: ____________________________________ (First) (Last) (Prefer home e-mail if available) Mailing address:_____________________________________ ______________________________________________ (MSDH employee – use complete courier address) City State Zip Phone: ________________ If MSDH employee: District # _____ Central Office: ____ APHA Member: Yes No (Daytime) (Circle) □ YES, I have received a 2014 MPHA membership card showing I am a current paid member. My 2014 Membership number is ________. You must also complete Sections B and C on reverse side to be properly registered to attend Conference. □ NO, I have not paid MPHA membership dues for 2014. (You must be a current 2014 member for Conference registration.) You must complete Sections A, B and C on both sides of this Form. □ MEMBERSHIP ONLY. If not registering to attend the 2014 Annual Conference and are ONLY Joining/Renewing 2014 membership, you may use this form and complete only SECTION A (front page) and return by mail to MPHA Membership, Post Office Box 4834, Jackson, MS 39296 or complete online at mspha.org with credit card. SECTION A MEMBERSHIP INFORMATION Membership Dues: (Check one) □ Regular $ 30.00 □ Contributing Membership $ 50.00 Type: (Check one) □ Retirees $ 15.00 □ New □ Renewal □ Students (F/T w/12 credit hours) $ 12.00 (member in 2013) □ Life Member $350.00 Section Dues: (Maximum of two sections) Joining a section is an optional component of MPHA membership. You must be a member of MPHA to join a section. Please check which section(s) you would like to join and include these dues with your MPHA annual dues (see below). All Section dues collected are returned to the section for its use. □ Environmental Health: $10 □ Nutrition: $10 □ Epidemiology: $10 □ Nursing: $10/nurses, $5/ aides/student nurses/retirees □ Health Administration: $10 □ Public Health, Education, Policy & Research, $10/regular $5/FT student □ Office Professionals: $6 □ Social Work: $8 □ Medical Care – None □ No Section Section(s) Dues Total $__________ TOTAL (Membership Dues + Section Dues) $__________ FOR CONFERENCE REGISTRATION, COMPLETE SECTIONS B AND C ON REVERSE SIDE Annual Conference Registration/Membership Form September 3-5, 2014 Jackson Hilton; Jackson, MS READ CAREFULLY & PRINT LEGIBLY
Transcript of Annual Conference Registration/Membership Form B CONFERENCE REGISTRATION Registration...
Name: ________________________________ Email address: ____________________________________ (First) (Last) (Prefer home e-mail if available) Mailing address:_____________________________________ ______________________________________________ (MSDH employee – use complete courier address) City State Zip Phone: ________________ If MSDH employee: District # _____ Central Office: ____ APHA Member: Yes No (Daytime) (Circle)
□ YES, I have received a 2014 MPHA membership card showing I am a current paid member. My 2014 Membership number is ________. You must also complete Sections B and C on reverse side to be properly registered to attend Conference.
□ NO, I have not paid MPHA membership dues for 2014. (You must be a current 2014 member for Conference registration.) You must complete Sections A, B and C on both sides of this Form.
□ MEMBERSHIP ONLY. If not registering to attend the 2014 Annual Conference and are ONLY Joining/Renewing 2014 membership, you may use this form and complete only SECTION A (front page) and return by mail to MPHA Membership, Post Office Box 4834, Jackson, MS 39296 or complete online at mspha.org with credit card.
SECTION A MEMBERSHIP INFORMATION Membership Dues: (Check one)
□ Regular $ 30.00 □ Contributing Membership $ 50.00 Type: (Check one) □ Retirees $ 15.00 □ New □ Renewal □ Students (F/T w/12 credit hours) $ 12.00 (member in 2013)
□ Life Member $350.00 Section Dues: (Maximum of two sections) Joining a section is an optional component of MPHA membership. You must be a member of MPHA to join a section. Please check which section(s) you would like to join and include these dues with your MPHA annual dues (see below). All Section dues collected are returned to the section for its use.
□ Environmental Health: $10 □ Nutrition: $10 □ Epidemiology: $10 □ Nursing: $10/nurses, $5/ aides/student nurses/retirees □ Health Administration: $10 □ Public Health, Education, Policy & Research, $10/regular $5/FT student
□ Office Professionals: $6 □ Social Work: $8 □ Medical Care – None □ No Section Section(s) Dues Total $__________
TOTAL (Membership Dues + Section Dues) $__________ FOR CONFERENCE REGISTRATION, COMPLETE SECTIONS B AND C ON REVERSE SIDE
Annual Conference Registration/Membership Form September 3-5, 2014
Jackson Hilton; Jackson, MS
READ CAREFULLY & PRINT LEGIBLY
SECTION B CONFERENCE REGISTRATION
Registration Deadlines/Info: ALL registration fees and conference attendance require 2014 MPHA membership.
August 12 Deadline for Paper Applications (Must be postmarked by Aug. 12) NO LATE FEE
August 13-24 ONLINE Only (After Aug. 12) $20 Late Fee Applied After August 24 ON-SITE Only $40 Late Fee Applied
Conference Registration Fees: Circle Amount & Add to Section C
MSDH Employee*
Other Public Health Professionals
Public Health Retiree
Full-time Student**
Full 3-day Registration $25 $110 $75 $60
Single day Registration $20 $65 $45 $30 *Registration subsidized by MSDH ** Attach copy of valid student ID
Full conference registration includes four meals (Wed. reception, Thurs. breakfast and lunch, Fri. breakfast, three breaks) and access to all training and events.
SECTION C PAYMENT
Membership/Section Dues (total from Section A) $_________
Conference Registration Fees (total from Section B) $_________
Tax Deductible Donation $_________
TOTAL REGISTRATION (FEES + MEMBERSHIP DUES + DONATIONS) $ _____________
Please make check or money order payable to MPHA attach to this completed registration form and mail to: MPHA Registration, Post Office Box 4834, Jackson, MS 39296.
Total Conference attendance limited to 450
OTHER INFORMATION
1. IMPORTANT: If you have not already renewed your 2014 membership or joined MPHA prior to May 15, 2014 you must become a current member (complete Section A) … and complete Sections B and C to be registered for the Conference.
2. If you have already joined MPHA in 2014 (January - May 15). YOU MUST STILL complete parts B and C of this Form to complete registration for the Conference.
3. Membership dues are non-refundable. Registration fees may be refunded at 75 percent (75%) if received in writing prior to August 26, 2014 or only extreme emergency after.
4. Additional Conference Information including Hotel Information, Awards, and Agenda Information will be updated on our website at www.mspha.org.
