SPECIAL EVENTS REGISTRATION FORM

Mental Health & Missions Conference - MHM
Potawatomi Inn & Conference Center, Angola, Indiana
Participant Info
Title
Full Name


MALE FEMALE
   
(spouse, if attending)
Title
Full Name
  MALE FEMALE
MAILING ADDRESS
(Business or Personal as you would like it to appear on the conference roster)
Street or PO Box
City
State
Zip
Country
Phone Numbers only please
E-mail
 
DEMOGRAPHIC INFORMATION:
Degree
Specialty
Organization
Position
Country/Region of Focus
REGISTRATION INFORMATION:
Roommate Preferance
 
First time attender? YES NO

Prefer to stay in a cabin? YES NO


Why are you coming to MHM? (Check all that apply)
Renewal Networking Community
Professional Training CEUs

ALL ROOMS IN THE INN ARE NOW SMOKE-FREE!!

 
PRICING:
MHM 2011 - November 17-20  

 
Registration November 1 - 17, meals and lodging
$506
Add for Single Occupancy
$140
   
PAYMENT OPTIONS: Payment in full is required at registration. Your registration is not complete until the payment is received by MTI.
Credit card online
Mailing check Please mail check today.
   
Comments
 
Cancellation Policy:
If cancellation occurs before October 1, $30 administration fee is non-refundable.
If cancellation occurs before November 1, $145 fee is non-refundable.
Total conference cost is non-refundable if cancellation occurs after November 1.
Phone registration and payment are also available by calling 800-896-3710.
 
Once you click the Submit button, it will take you to our secure on-line credit card processing system. If you are paying by credit card, please continue. If you are mailing a check, please click Submit and then close the window.
 

 

 

  CALL 800-896-3710
 

 

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