Midwifery Today Conference
|First Name / Given Name||Last Name / Surname||Name to appear on badge (if different)|
|Street Address / P.O. Box||City|
|State / Province / Region||ZIP / Postal Code||Country|
How are you involved in birth?
|Direct-entry midwife||Licensed midwife||Certified nurse-midwife||Student midwife|
|Aspiring midwife||CPM||RN||Naturopath||Childbirth educator||Midwife educator|
|Doula / LA||Other ____________________|
How many births have you attended? _________
|How did you hear about this conference?|
|What excites you about this conference?|
Do you give permission for Midwifery Today to release your name and address to fellow registrants?
I will attend classes on these days (select all that apply):
|Wednesday Pre-Conference||Thursday Pre-Conference||Friday Conference||Saturday Conference||Sunday Conference|
Please tick off each class you will attend. Select one class from each set of concurrent sessions offered on the days you will attend. For example, if you will attend the conference on Friday, you need to select one class from C1 through C5 and also one class from D1 through D5. Class descriptions can be found in the conference program.
Select a full-day course (Either 9:00 am – 5:00 pm OR 8:30 am – 4:30 pm; see program):
Select a full-day course (9:00 am – 5:00 pm):
Select one class (1:00 pm – 2:30 pm):
Select one class (2:45 pm – 4:15 pm):
Select one class (10:15 am – 12:15 pm):
Select one class (1:30 pm – 3:00 pm):
Select one class (11:15 am – 12:45 pm):
Midwifery Today is an English language publication, published four times per year. Each issue contains 72 pages of articles, stories, and opinions, written by midwives and other birth practitioners from around the world.
|Address||Price for 1-year subscription to Midwifery Today|
|United States||U.S. $55||---||---|
|Canada / Mexico||U.S. $68||---||---|
If you would like to subscribe to Midwifery Today, please select the appropriate box below and enter your subscription price in the Payment section of this form.
|Please begin my subscription.||Please renew my subscription.||I am already a subscriber.|
Prices do not include meals, transportation or overnight accommodations. Look up your price in the table in Section 5.
If you are a subscriber to Midwifery Today, you may deduct 10% from your conference price. Subscription may be started at time of conference registration, but must be current at time of registration to qualify for discount. Midwifery Today magazine is an English language publication. Student discount does not apply to subscription prices.
If you are a full-time student, you may deduct 20% from your conference price. You must register for three or more days; and you must submit, with your registration, proof of full-time student status.
If you qualify for a discount, please select the appropriate box below and enter the amount of your discount in the Payment section of this form.
|Subscriber [ 10% ]||Full-time student [ 20% ]||Subscriber and full-time student [ 30% ]|
|Attendance||Conference prices when your registration is postmarked on or before…||Conference prices when your
registration is received
in-office by 7 October 2013;
please do not mail
registrations to be received
later than this deadline.
|17 June 2013||15 August 2013|
|1 day||U.S. $150||€120 †||£95 †||U.S. $160||€130 †||£100 †||U.S. $170||€140 †||£105 †|
|2 days||U.S. $300||€240 †||£190 †||U.S. $320||€260 †||£200 †||U.S. $340||€280 †||£210 †|
|3 days||U.S. $400||€320 †||£250 †||U.S. $425||€345 †||£265 †||U.S. $450||€370 †||£280 †|
|4 days||U.S. $550||€440 †||£345 †||U.S. $585||€475 †||£365 †||U.S. $620||€510 †||£385 †|
|5 days||U.S. $590||€480 †||£380 †||U.S. $630||€520 †||£400 †||U.S. $670||€560 †||£420 †|
|† Please select the price in U.S. dollars when you pay by credit card.|
Walk-in registrants are welcome, but you should check with Midwifery Today to learn the availability of classes. When you arrive at the conference, simply pay the price listed in the table for 7 October.
Please calculate the amount you need to pay by completing the items below.
|Enter your conference price from the table above.|
|If you qualify for a discount (see the Discounts section above), enter the amount of your discount (multiply your conference price by 10%, 20% or 30%). Enter 0 if you do not qualify for a discount.|
|Subtract your discount from your conference price.|
|If you are subscribing to Midwifery Today (see the Subscription section above), enter your subscription price. Enter 0 if you are not subscribing at this time.|
|Add the items above to calculate your total payment.|
How will you make your payment? NOTE: Credit cards will be charged in U.S. dollars.
|Check in U.S. dollars||Cheque in Euros||Cheque in sterling||Bank transfer in Euros||Visa||MasterCard|
If you pay by cheque or money order, make it payable to Midwifery Today. Payment may be made in sterling, Euros or U.S. funds.
All credit cards will be charged in U.S. dollars at the listed U.S. prices. We cannot make any guarantee of exchange rate. All fees for fund conversion are the responsibility of the payer.
Midwifery Today, Inc., account at:
HSBC Bank plc, 60 Queen Victoria St, London, EC4N 4TR England
Account number: GB06 MIDL 4005 1557 1644 96
BIC code: MIDLGB22
Important: Include registrant name(s) with funds transfer.
Note: The sender is responsible to pay any bank fee charged for the transfer.
Please e-mail email@example.com for details.
No refunds will be given after 13 September 2013. A processing fee equal to 30% of the amount paid will be deducted from any refund given on or before this date.
Please complete the following items if you are paying by Visa or MasterCard.
|Amount to be charged to your credit card in U.S. dollars|
|Account number (Visa/Mastercard)*|
*Must be 16-digit number starting with a “4” or “5”
|Expiration date [ month / year ]|
|Name as it appears on the credit card [ please print ]|
|Billing address if different from above [ please print ]|
|Billing phone and/or e-mail address [ please print ]|
Please read and complete all of this form. Then make a photocopy for your records.
You may mail this form with your payment in sterling, Euros or U.S. funds to Midwifery Today. If you pay by credit card or bank transfer, you may fax this form to Midwifery Today. You may also register by phone or e-mail. (Do not send credit card details by e-mail.) Use the Contact Addresses and Telephone Numbers at the bottom of this form.
Registrations must be received in office at Midwifery Today no later than 7 October. If you cannot mail your registration early enough for it to be received prior to this deadline, please register at the conference.
Please see information on location and accommodations on our Belgium gateway page.
A certificate of attendance will be provided to each participant. No U.S. CEUs will be provided.
P.O. Box 2672
Eugene, OR 97402-0223
1-800-743-0974 [ U.S. and Canada only ]
+1 541-344-1422 [ fax ]
Up-to-date conference information can be found on the Midwifery Today Web site:
Midwifery Today, Inc., cannot be held responsible for natural disasters, labor strikes, acts of war or other events that may cause the conference to be rescheduled. Midwifery Today, Inc., reserves the right to postpone the conference to another time, date and if necessary, location. In the event of a conference postponement no refunds will be issued. Registrants can transfer their fees toward any other Midwifery Today conference.
Midwifery Today, Inc., reserves the right to substitute teachers and/or classes. The views and opinions expressed by teachers are their own and may not represent the views and opinions held by Midwifery Today, Inc., and its staff members.