2023 Mississippi disAbility MegaConference

Personal Information

• * First Name:
• * Last Name:
• Company/Organization
• * Email Address:
• * Confirm Email Address:
• * Address 1:
• * City:
• * State: --Choose-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming -------------- Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory
• * ZIP Code:
• * Phone:
• Cell Phone:
• If you have a personal care attendant with you, please list their name.

• Promo Code

  Enter Code: Apply

• Fee

  Type	Fee
  Parent or person with disability	$50.00
  Student (register using school email address)	$35.00
  Professional	$175.00
  Exhibitor	$325.00

Guest Information

You may add a maximum of 10

General Conference Information

• CANCELLATION NOTICE: The registration fee for this event is forfeited if attendance is cancelled. You may send a substitute. As a courtesy to the planners, written notice of your intent not to attend or to send a substitute is appreciated by May 22, 2023. Notice can be made by email to brittany@mspti.org.

• How many people will be attending the Pre-Conference Evening Event on Monday, June 5 from 6:30 pm - 8:00 pm? IF YOU ARE BRINGING SOMEONE TO THE PRE-CONFERENCE EVENT THEY MUST BE REGISTERED UNDER SPOUSE/CHILDREN. (If none, type 0 in the box).
• How many people will be attending the gala reception on Tuesday, June 6 from 6:00 pm - 9:00 pm? IF YOU ARE BRINGING SOMEONE TO THE GALA THEY MUST BE REGISTERED UNDER SPOUSE/CHILDREN. (If none, type 0 in the box).

Conference Accommodations:

• Please mark all that apply:

  • Large Print
  • Braille
  • Sign Language Interpreter
  • Conference Buddy
• Other:

• Meal Accommodations:

  • Diabetic
  • Gluten Free
  • Low-Sodium
  • Vegetarian
• Other:
• Continuing Education Credits: Please indicate what type (example: CEU, etc.)

• The educational portion of this activity is presented by the Mississippi Department of Mental Health, Division of Professional Development. Continuing education is a separate registration which is required at the beginning of the conference. Planning Forms have been submitted for review for continuing education credit. Once additional credits are approved, a more specific language will be added to the website (www.msmegaconference.org). Subject to Approval.

• Purchase Order Number (please mark pay by check)