Mental Health Awareness Week 2021 Event Registration Form
Mental Health Awareness Week 2021 Date: 3/10/2021 - 10/10/2021 Theme - Mental Health in an unequal World Venue –Eldoret
Full Name
*
First Name
Middle Name
Last Name
Gender
Please Select
Male
Female
N/A
E-mail
*
example@example.com
Mobile Number
-
Area Code
Phone Number
Profession
*
Enter MPAK Member ID(if an MPAK Member)
*
If not put N/A
Institution and student ID(if a student)
*
if not put N/A
Are you a registered member with MPAK?
*
Yes
No
If yes, select your membership status:
Please Select
Associate
Student
Certified Medical Psychologist
Chartered Medical Psychologist
Kindly select all the days you'll be available to attend the event: (multiple selection allowed)
Payment
Payment is needed to complete registration. For an added security on this form, the QR code below when scanned should open the MPAK website.
Registration categories, kindly select the one you're paying for:
prev
next
( X )
MPAK Member
2,000.00
KES
Student
1,000.00
KES
Non MPAK Member
3,000.00
KES
Payments to be sent to MPESA No: 0700131666, Name: Julius Barasa, MPAK Treasurer.
Payment confirmation code to be added below
To complete registration, enter the amount sent and MPESA confirmation code:
*
Submit Application
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