First Name                                                  MI           Last Name                             Degree(s)                 Title/Position                                                                     WSEHA/WSPHA I.D. #
 

   Agency Name and Mailing Address
       Phone:   (Example: 206-555-1212)
            Fax:      
      E-Mail:      *Form will not submit if yellow fields are not completed.
         
   I.D. # & Institution (only full-time students qualify for student rates)       Oral Presenter/Panelist    Presenting Monday    Presenting Tuesday    Presenting Wednesday
     Vegetarian meals        Braille or sign interpreter needed?    Are you an Exhibitor or Break Sponsor?

     Applying for CHES Credits      Applying for RS Credits         Poster Presenter     I am interested in moderating a session

 Comments:     Attending Community Environmental Health Assessment Session on 10/5/08     

 
  Registration Fees: First amount is for full conference, second amount is for one day.  If you select one day remember to also select which  day you are planning to 
 attend.  Student scholarship option is located below this section.  Discounted fees apply only to WSPHA or WSEHA members.  Memberships will be verified - if you are
 unsure of your membership status please contact Kathy Kondakjian before processing your payment on-line.

  Registration Fee:  $260 (full)     $175 (one day - indicate which day on the right)   Mon 10/6     Tue 10/7     Wed 10/8
 
  Discounted Fee (WSPHA/WSEHA member only):  $210 (full)     $125 (one day)    Mon 10/6     Tue 10/7    Wed 10/8

  Student Registration Fee:   $150 (full)    $110 (one day - indicate which day on the right)     Mon 10/6     Tue 10/7     Wed 10/8

  Discounted Student Fee (WSPHA/WSEHA members only):    $100 (full)       $60 (one day - indicate day to the right)       Mon 10/6      Tue 10/7     Wed 10/8

  Retired Registration Fee:    $150 (full)     $110 (one day)       Mon 10/6      Tue 10/7      Wed 10/8

  Discounted Retired Fee (WSPHA/WSEHA members):   $100 (full)    $60 (one day - indicate which day on the right)    Mon 10/6    Tue 10/7   Wed 10/8   

  Onsite Registration Fee:   $275 (full)     $195 (one day)    Mon 10/6       Tue 10/7      Wed 10/8
 
  Discounted Onsite Registration (WSPHA/WSEHA members):   $225 (full)    $140 (one day - indicate which day on the right)    Mon 10/6    Tue 10/7  10/8
 
  Payment for registration will be made by:   Purchase order from my agency            Check from my agency               Personal Check    

  Credit Card Payment*  Type of credit card:  American Express      Master Card         Visa

  Name of the Card Holder (necessary to properly match payment with registration(s):

 I am contributing as a sponsor for JCH under the category of Prime, Major, Key, or Sponsor and am receiving a complementary registration.

  Comments/Other:

  I am requesting a Student Conference Scholarship.  I understand that I must be a student enrolled at least half-time and a member of WSPHA.

WSPHA/WSEHA Membership: As a registrant of this year's Joint Conference you qualify for a special membership rate of $75 which includes dual membership in both the Washington State Public Health Association and Washington State Environmental Health Association.  Individually, these memberships are $50 each but as a registrant of the 2008 JCH you can obtain membership in both organizations for one full year at the rate of $75.  To take advantage of this offer simply return to the WSPHA homepage and click on the link for Memberships.  Complete the on-line membership form to pay by credit card or to pay by check print out the membership form and mail with your check.  As a member of either WSEHA or WSPHA you will qualify you for the discounted registration rate for this year's JCH.

Paying by check,  money order, or purchase order: Please print out this form before submitting it below.  Mail or fax in a copy with purchase order or payment. Payment will be matched up with the electronic registration received over the site.  Fax number is (425) 357-9694.  Mailing address: WSPHA, 4617 144th Pl. SE, Snohomish, WA  98296-6916.

Paying by credit card: *The link for processing on-line credit card payments is located on the confirmation page which will come up after you click on the submit button below.  Please print this completed form and click on submit.  Please Note: If you are paying for more than one person by credit card and/or the registrant's name is different from that of the credit card holder, you may be asked to provide a list of  names being paid by the credit card - especially if you go on-line more than once to process multiple payments with the same card.  The billing address must be an identical match to the billing address on the credit card statement or else the card will be declined.  WSPHA is charged for every attempt to process credit cards.  Please check you billing statement for accuracy on the billing address before you submit.  If you have questions please contact Kathy Kondakjian at 425-337-5717 or email kathy@wspha.org.