MEPC Registration Form Step 1 of 3 33% Type of Registration*- Select your registration type -General Attendance - $495Single Day Registration - $250*Already Registered - Adding Spouse, Guest(s), Children, Golf or Childrens Program - Cost will be determinedSelect Day*- Please select the day you would like to attend -Wednesday 7/24/19Thursday 7/25/19Friday 7/26/19PROMO CODEIs this your first time attending MEPC?*NoYesIf this is your first time attending, please enter the name of the person who referred you under "How did you hear about the MEPC?" section below.How did you hear about the MEPC?Registrant InformationName* First Last Name on Badge*Job Title or description*Organization*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Registrant Email* Enter Email Confirm Email Cc Email Enter Email Confirm Email Golf OutingWould you like to register for the golf outing on Thurday 7/25/19? Yes. I would like to register for the golf outing. Name #1 ($110) First Last Name #2 ($110) First Last Name #3 ($110) First Last Name #4 ($110) First Last Name #5 ($110) First Last Register Additional Guests*A Registered Guest can attend all conference events such as receptions and meals but are not permitted into the conference sessions. If your Guest would like to attend the conference sessions, they will need to register as a General Attendee. Would you like to register additional guests? Yes. I would like to register additional guests. Guest #1 ($150) - Name First Last Guest #2 ($150) - Name First Last Guest #3 ($150) - Name First Last Guest #4 ($150) - Name First Last Guest #5 ($150) - Name First Last Guest #6 ($150) - Name First Last Register ChildrenWould you like to register any children? (17 and under) Yes. I would like to register children Child #1 ($40) - Name First Last AgeChild #2 ($40) - Name First Last AgeChild #3 ($40) - Name First Last AgeChild #4 ($40) - Name First Last AgeChild #5 ($40) - Name First Last Age Reception InformationNumber Attending Wednesday Reception*Number Attending Thursday Cocktail Reception*Would you like to register for Thursday evening's Children’s Program?PLEASE NOTE: Children MUST BE Registered for the Conference in order to Register for the Children's Program. Yes. I would like to register for Thursday evening's Children’s Program. Child #1 ($5) - Name First Last Age*Child #2 ($5) - Name First Last Age*Child #3 ($5) - Name First Last Age*Child #4 ($5) - Name First Last Age*Child #5 ($5) - Name First Last Age* Terms and ConditionsCancellations: MEPC must be contacted via email or phone by July 8, 2019 to be eligible for a refund. A $25.00 cancellation fee will be applied. No refunds will be made after July 8, 2019.Media Consent*Please be aware that by registering for this event, you consent to your image, voice, name, and/or likeness being used, without compensation, on MEPC's website, communications, promotional material, or the websites/ social media of others in attendance, whether now known or hereafter devised, for eternity, and you release MEPC, its successors, assigns, and licensees from any liability whatsoever of any nature.Yes, I consent.No, I do not consent.Payment OptionsPlease select your payment option*Invoice my OrganizationPay by credit card*Speaker/SponsorSpecial NeedsPlease note any special needs (IE: Accessibility, Dietary requirements)Questions or Concerns (We will reply)Emergency ContactName* First Last Phone*EmailThis field is for validation purposes and should be left unchanged.