Registration - Missouri Department of Mental Health's Spring Training Institute 2011

Please fill out the form below. A confirmation with further information will be sent upon receipt of your payment.

or use this STI Printable Registration Form (right-click and choose save-as)

Conf:
Price: * $190 full program
$100 Thursday only
$100 Friday only


$215 full program with printed handout
$125 Thursday only with printed handout
$125 Friday only with printed handout
Location* Thursday and Friday May 19 and 20, 2011 at Tan-Tar-A, Osage Beach, MO
Payment Options * Credit Card
Bill My Employer
Name *
Address *
City *
State *
Zip *
Email Address *
Daytime Phone *
Profession
Degree
Employer *
Work Address *
Work City *
Work State *
Work Zip *
Work Phone *
Purchase Order Number *
Fiscal Contact’s Name
Fiscal Contact’s Phone

* = required fields

* = required field only when paying by invoice


If paying by credit card (Visa or MasterCard only), you will be forwarded to the University of Missouri’s QuikPay system in order to enter card information.

If paying by invoice, we will send your conference registration upon receipt of a hard copy of your purchase order.

Cancellations or Substitutions:
If you are unable to attend, we ask that you notify us as soon as possible. Cancellations received in writing five business days prior to the date of the program will be refunded, less a $25.00 processing fee. You may send a substitute, but we ask that you notify us in writing of this change. If you do not attend or send a substitute, you or your employer will be billed the full registration fee.

or use this STI Printable Registration Form (right-click and choose save-as)

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MIMH Continuing Education
5400 Arsenal Street
St. Louis, MO 63139
(314) 877-6419
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