The 2ndAnnual Mississippi School for Addiction Professionals
Prevention, Intervention, & Treatment
Hattiesburg, MS
January 20 – January 23, 2009
PARTICIPANT REGISTRATION FORM
Please complete a separate form for each individual.
Title: Mr. Mrs. Ms. Dr. Prof.
Name: (preference for appearance on name badge)
________________________________________________________________________________
(FIRST) (LAST)
Organization: ______________________________________________________________________
Address:___________________________________________________________________________
City: ________ _____________ State/Province: __________ ____ Postal/Zip Code: __________
Telephone: (______)__________________ Fax: (______)____________________
Email: _______________________________
Please check the website and indicate your top two class preferences for the following days:
Wednesday: #1 A- #2 A- Thursday: #1 B- #2 B-
NOTE: If the Prevention Course (A9) is chosen participants must remain in that course both days.
Friday’s classes will be open to all participants.
Registration Fees - Includes the cost of registration, book of abstracts, conference proceedings, conference
reception, 2 continental breakfasts, 2 lunches, and coffee breaks.
Please Check One:
Postmarked by December 15, 2008 $250 $ ________
Postmarked after December 15, 2008 $280 $ ________
On-site registration $300 $ ________
Total $ ________
Dietary Limitations (please explain):
Cancellations and Refunds: Registration fees will be refunded, less a $25.00 administration fee, if cancellation is
received in writing no later than January 01, 2008. After that date, registration fees are non-refundable. All
refunds will be processed after the conference. Registration fees are transferable.
PAYMENT METHOD
The Mississippi Department
Please remit payment by Check or Money Order in U.S. funds payable to:
of Mental Health. There will be a $30.00 fee charged on checks returned by the bank due to
insufficient funds.
If organization is paying for more than one person, one check with group total is acceptable. Include
code JSMS08-1 on your form of payment.
(Please check appropriate box) Check Money Order
Please mail completed registration form with payment to: Mississippi Dept. of Mental
Health
ATTN: Jerri Avery
1101 Robert E. Lee Building
239 N. Lamar Street
Jackson, MS 39201
Phone: (601) 359-1288
Email: theMSschool@dmh.state.ms.us
There is a $10 contact hour fee for those participants seeking CEU credits. Mississippi Department of Mental Health participants are exempt.