MSDH Registration

MSDH Employee CHW Summit Registration Form

Please enable JavaScript in your browser to complete this form.

MSDH Employee Name

First

Last

This registration is ONLY for MSDH Employees. Your $25 registration fee will be paid by your department. This list is monitored and reviewed weekly. If you are not an MSDH employee and register, you will be removed from the official list.

Layout

Credentials

Name as if you like to see on the Badge.

Company Name

Address

Address Line 1

City

State / Province / Region

Postal Code

Country

Layout

T-Shirt Size

Phone

Registration Type

If you are a CHW, what area do you work?

Example is Transportation, Housing, Health Education, etc.

Emergency Contact Information

Layout

Name

Phone

Do you need hotel accomodations?

Yes
No
I am local, no hotel needed.

We will share hotel rates with all who have registered when link is ready.

Summit Cancellation.

Cancellation requests must be received in writing on or before March May 10th, 2024. For summit registrations, a refund will be issued minus an administrative fee of $10.00. Substitution requests must be submitted in writing.

Agreement

I have read and understand the above Summit Cancellations and Changes

Registrations received without payment will not be processed. Registration payments will go towards membership to MSCHWA.

I hereby grant permission to the Mississippi Community Health Workers Association (MSCHWA) to use photographs and/or video recordings of me taken during the Summit for promotional purposes. I understand that these materials may be used in various publications, websites, social media platforms, or other promotional materials related to MSCHWA and its activities. I waive any right to inspect or approve the finished product wherein my likeness appears. I also waive any right to royalties or other compensation arising or related to the use of the photographs and/or video recordings. I hereby release, discharge, and agree to hold harmless MSCHWA and its representatives from any and all claims, demands, or causes of action that I may have now or in the future, arising out of or related to the use of the photographs and/or video recordings, including but not limited to any claims for defamation, invasion of privacy, or infringement of moral rights. I understand that my participation in the event is voluntary and that I have the right to refuse to be photographed or recorded. By signing below, I acknowledge that I have read and understood the terms of this photo release consent and agree to its provisions.

Yes, I agree to the above.
No, I do not want my photo shared on Social Media or with Promotional Marketing.

Questions? Email info@mschwa.org

Emergency Contact Information

About Us

Important Links

Contact Info

Copyright © 2024 Mississippi Community Health Workers Association Summit

Site Designed By RNM Marketing