MSAAP Virtual Conference Registration

Name*

First NameLast Name

Credentials*

MDDOPhDOther

Please enter credentials if "Other" is selected:

Clinic*

Phone Number*

Please enter mobile number to receive texting campaign.

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Member?*

YesNo

Please select one of the following:*

PhysicianResident/StudentOther Professional

Registration Fee:*

AAP Member and Non Member - $25.00Resident / Student ( Residents and students may attend at no charge. Must provide proof of residency and/or student ID to qualify.)

PAYMENT INFORMATION:

USDEnter the amount to be charged to Credit Card

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

CANCELLATION

Refunds may be granted if written cancellation is received 10 working days prior to the conference in writing. MSAAP reserves the right to cancel this program is sufficient pre-registrations are not received. If the event is canceled, all prepaid registration fees will be refunded in full. All correspondence should be sent to: MS-AAP, P.O. Box 296, Madison, MS 39130, or e-mail director@aapms.org

Mississippi Chapter of the American Academy of Pediatrics | P. O. Box 296 | Madison, MS 39130 | www.aapms.org

2023 Suicide Prevention CME Virtual Conference