2024 Mid-Fall Statewide Conference Registration

Thank you for your interest in registering for our 2024 Statewide Mid-Fall Conference!

Please fill out all required information below.
How many people would you like to register?*
1. Name*

First NameLast Name
1. Title*
1. Email*
example@example.com
Membership Type: (Select the choice that applies below)*
Member Rate (Select Registration Type)*
Non-Member Rate (Select Registration Type)*
Daily Rate (How many days are you paying for?)*
Daily Rate (Which days will you be attending)?
2. Name*

First NameLast Name
2. Title*
2. Email*
example@example.com
Membership Type: (Select the choice that applies below)*
Member Rate (Select Registration Type)*
Non-Member Rate (Select Registration Type)*
Daily Rate (How many days are you paying for?)*
Daily Rate (Which days will you be attending)?
3. Name*

First NameLast Name
3. Title*
3. Email*
example@example.com
Membership Type: (Select the choice that applies below)*
Member Rate (Select Registration Type)*
Non-Member Rate (Select Registration Type)*
Daily Rate (How many days are you paying for?)*
Daily Rate (Which days will you be attending)?
4. Name*

First NameLast Name
4. Title*
4. Email*
example@example.com
Membership Type: (Select the choice that applies below)*
Member Rate (Select Registration Type)*
Non-Member Rate (Select Registration Type)*
Daily Rate (How many days are you paying for?)*
Daily Rate (Which days will you be attending)?
5. Name*

First NameLast Name
5. Title*
5. Email*
example@example.com
Membership Type: (Select the choice that applies below)*
Member Rate (Select Registration Type)*
Non-Member Rate (Select Registration Type)*
Daily Rate (How many days are you paying for?)*
Daily Rate (Which days will you be attending)?
6. Name*

First NameLast Name
6. Title*
6. Email*
example@example.com
Membership Type: (Select the choice that applies below)*
Member Rate (Select Registration Type)*
Non-Member Rate (Select Registration Type)*
Daily Rate (How many days are you paying for?)*
Daily Rate (Which days will you be attending)?
7. Name*

First NameLast Name
7. Title*
7. Email*
example@example.com
Membership Type: (Select the choice that applies below)*
Member Rate (Select Registration Type)*
Non-Member Rate (Select Registration Type)*
Daily Rate (How many days are you paying for?)*
Daily Rate (Which days will you be attending)?
8. Name*

First NameLast Name
8. Title*
8. Email*
example@example.com
Membership Type: (Select the choice that applies below)*
Member Rate (Select Registration Type)*
Non-Member Rate (Select Registration Type)*
Daily Rate (How many days are you paying for?)*
Daily Rate (Which days will you be attending)?
9. Name*

First NameLast Name
9. Title*
9. Email*
example@example.com
Membership Type: (Select the choice that applies below)*
Member Rate (Select Registration Type)*
Non-Member Rate (Select Registration Type)*
Daily Rate (How many days are you paying for?)*
Daily Rate (Which days will you be attending)?
10. Name*

First NameLast Name
10. Title*
10. Email*
example@example.com
Membership Type: (Select the choice that applies below)*
Member Rate (Select Registration Type)*
Non-Member Rate (Select Registration Type)*
Daily Rate (How many days are you paying for?)*
Daily Rate (Which days will you be attending)?
11. Name*

First NameLast Name
11. Title*
11. Email*
example@example.com
Membership Type: (Select the choice that applies below)*
Member Rate (Select Registration Type)*
Non-Member Rate (Select Registration Type)*
Daily Rate (How many days are you paying for?)*
Daily Rate (Which days will you be attending)?
12. Name*

First NameLast Name
12. Title*
12. Email*
example@example.com
Membership Type: (Select the choice that applies below)*
Member Rate (Select Registration Type)*
Non-Member Rate (Select Registration Type)*
Daily Rate (How many days are you paying for?)*
Daily Rate (Which days will you be attending)?
13. Name*

First NameLast Name
13. Title*
13. Email*
example@example.com
Membership Type: (Select the choice that applies below)*
Member Rate (Select Registration Type)*
Non-Member Rate (Select Registration Type)*
Daily Rate (How many days are you paying for?)*
Daily Rate (Which days will you be attending)?
14. Name*

First NameLast Name
14. Title*
14. Email*
example@example.com
Membership Type: (Select the choice that applies below)*
Member Rate (Select Registration Type)*
Non-Member Rate (Select Registration Type)*
Daily Rate (How many days are you paying for?)*
Daily Rate (Which days will you be attending)?
15. Name*

First NameLast Name
15. Title*
15. Email*
example@example.com
Membership Type: (Select the choice that applies below)*
Member Rate (Select Registration Type)*
Non-Member Rate (Select Registration Type)*
Daily Rate (How many days are you paying for?)*
Daily Rate (Which days will you be attending)?
Agency/Organization Information*

Agency/Organization Name

Street Address

CityState

Zip Code
Contact Email*
example@example.com
Contact Phone Number*
Please enter a valid phone number.

CONFERENCE DETAILS
Which affiliate association is your organization a member of?*
Please Note: Agency & Participants must be members to qualify for the member rate. Agencies will be billed the non-member rate if non-members are registered at the member rate.
Are you an individual member of the SCSHSA?*
Are you an individual member of the SCCAP?*
SC Endeavors ID (if applicable)

PAYMENT DETAILS
Total Amount Due ($)
Membership Type: (Select the choice that applies below)*
Member Rate (Select Registration Type)*
How many days are you paying for?*
Non-Member Rate (Select Registration Type)*
How many days are you paying for?*
Select Payment Method*
Check #*
Purchase Order #*
***Your online payment will be handled via PayPal on the next page. Please note that PayPal charges a small fee for online processing.

ONLINE PAYMENT DETAILS
Paying online

prevnext( X )
USDDescription

Click Review Your Answers to verify your information is correct. After verifying, press the Submit button.
Should be Empty:

CONFERENCE DETAILS

PAYMENT DETAILS

ONLINE PAYMENT DETAILS