2020 MCI Registration

MCI Symposium/Workshop/Forum Registration
Badge Information

Information which will be printed on your badge
Full Name*

First NameLast Name
Suffix (Choose all that apply)*

PhDMDPsyDDOLCSWMSWRNMBAMSMABSBAOther
Organization*
City, State/Province*
Would you like to include your name and organization (only) on the list of participants (to be distributed at the event)?*

YesNo
Main affiliation/Industry*
Please detail "Other"
Contact Information

Please enter your contact information
Contact Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Phone Number (use "1" for US)*

Country CodeArea CodePhone Number
E-mail*

Confirmation Email
Logistics

A few questions to help us prepare for your participation and serve you better
How did you hear about the event?*

Email from organizersPostcardWebsiteEvent DirectoryWord-of-MouthAttended previous editionsOther
Will you require CME or CE credits?*

CMECENo credits needed
If you have a physical, dietary or communication need that may affect your participation in conference activities, please note so here.
Although the organizers will attempt to accommodate each special request, no guarantees can be made.
Registration Categories

Please select the appropriate delegate category and event:
To encourage local participation, Mount Sinai Medical Center is generously offering all Florida residents 50% off early-bird fees - they may use coupon code FLORIDAORG20. Please note that a Florida residence will be required at the time of payment and conference check-in.

Registration Category and Event (Symposium/Workshop/Forum) selection:

PHYSICIAN REGISTRATION (MD, DO, MDCM, etc.)$550.00

Now select the event(s):
Item subtotal:$0.00

NON-PHYSICIAN REGISTRATION (PhD, LCSW, MSW, MS, etc.)$450.00

Now select the event(s):
Item subtotal:$0.00

STUDENT/POST-DOCTORAL FELLOW REGISTRATION*$250.00

Now select the event(s):
Item subtotal:$0.00

PUBLIC EDUCATIONAL FORUM$ Free

NETWORKING RECEPTION GUEST** (accompanied by paying delegate)$35.00

Enter coupon

Total $0.00

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

* Academic credentials will be requested at check-in.

** Registrant's reception guest access to the networking reception only, January 18, 2020. Guest must be accompanied by a paying delegate.
ADMIN COMMENTS
Should be Empty:

Badge Information

Contact Information

Logistics

Registration Categories