Midwest Dermatology Conference Registration Form

Badge Information

First and Last Name for your Name Badge*

Credentials for your name badge*

Office Location / Employer*

Office City / State*

Meal Selection

The Conference program fee includes breakfast, lunch and coffee breaks for the PARTICIPANT ONLY, as detailed in the Conference Program.

Please check the meals you plan to attend:

Registration Options

General Conference Registration*

*Special Conference Registration Rates will be refunded to eligible registrants no later than the end of the meeting in the form of a $100.00 Visa/ Mastercard Gift Card. The room must be booked under the registrants name in order to receive credit for attendance. A comprehensive list will be obtained from hotel staff throughout each day of the conference to validate stay.

**Current and Valid Student IDs must be presented. Prior approval for student attendance must be obtained before the start of the conference. On-Site student registration cannot be guaranteed if the conference space is sold out. Please send an email to Joy Logothetis, PA-C at Illinoisdermpa@gmail.com to inquire about student registration and pricing.

I have read and agree to the terms of the photographing & recording policy.*

Yes

No

I have read and agree to the terms of the cancellation policy.*

Yes

No

Total Cost