2023 MHS Convention Registration Form

2023 Convention Registration Form

DoubleTree by Hilton - Springfield, MO - March 2-4, 2023
Name*

First Name Last Name
Company Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Email*
example@example.com
Member Status

MemberNon-Member
Professional Title

Hearing Instrument SpecialistAudiologistStudentHIS In-TrainingNon-Licensed Support Staff
IHS or AAA Number*
Your IHS number is the last four digits of your SSN. IHS requires this information to issue CE certificates. If you do not need CEs/CEUs, enter N/A.
Please select state(s) where CEUs are needed:

IllinoisIowaKansasMissouriNebraskaOklahoma
I plan to attend:*

In PersonVirtually
Registration Options*
prevnext( X )
Regular Member$295.00

Regular Member - Virtual$395.00

Associate/Individual/Student Member - No CEs$160.00

Associate/Individual/Student Member - No CEs - Virtual$260.00

Non-Member$420.00

Non-Member - Virtual$520.00

Regular Member (Friday Only)$147.50

Regular Member - Virtual (Friday Only)$197.50

Associate/Individual Member (Friday Only)$80.00

Associate/Individual Member - Virtual (Friday Only)$130.00

Non-Member (Friday Only)$210.00

Non-Member - Virtual (Friday Only)$260.00

Regular Member (Saturday Only)$147.50

Regular Member - Virtual (Saturday Only)$197.50

Associate/Individual Member (Saturday Only)$80.00

Associate/Individual Member - Virtual (Saturday Only)$130.00

Non-Member (Saturday Only)$210.00

Non-Member - Virtual (Saturday Only)$260.00

Exhibit Hall/Meals Only (Spouse Option - No CEs)$160.00

Total $0.00
Spouse Name (If Applicable)

First Name Last Name
Full refund of fee will be made if cancellation notice is received at least two weeks prior to the opening date of the convention. (Must be postmarked February 16 or before). A 50% refund will be made if cancellation is received by 5:00 p.m. February 21, 2023. NO REFUNDS WILL BE MADE AFTER FEBRUARY 22, 2023.
Should be Empty:

Now create your own Jotform - It's free!Create your own Jotform

2023 Convention Registration Form