Attendee Registration

Attendee Registration Form - Summer Conference

Registration Type(Required)

Facility Name(Required)

Other Facility Name(Required)

Name(Required)

First Last

(This name will appear on your name badge.)

Email Address(Required)

Address(Required)

Street Address City State Zip

Title(Required)

(e.g., Administrator, Director, Social Worker, Case Manager)

Professional License Number(Required)

(e.g., Administrator – #12345, Social Worker – #67890) If you do not hold a professional license, please enter “N/A."

Phone(Required)

Are you bringing any guests?(Required)

How many guests will you be bringing? (Required)

Price: $100.00

Total Registration Fee

This includes your registration and guest fees.

Guest Name (s)(Required)

Payment Method(Required)

Credit Card

Mail a Check

Invoice Me

Credit Card

Cardholder Name

Card Details

Mail your check to: INHA P.O. Box 458 Wiggins, MS 39577

You’ll receive an invoice within 2–3 business days.

Signature(Required)