ISPN

  Conference Registration Form
ISPN Psychopharmacology Institute and Annual Conference

March 7-11, 2017
Baltimore Marriott Inner Harbor at Camden Yards
Baltimore, MD,  USA

The Future of Mental Health Practice:
Connect, Collaborate, Differentiate

 

Please complete the information on this form, then click on the Continue button at the bottom of the page.

This form is for credit cards only. One form per registrant.

To pay by check, download this form and fax or mail to:
Address: ISPN • 2424 American Lane, Madison, WI 53704  USA • Fax: +1-608-443-2478 or +1-1-608-443-2474
(Registration by telephone will not be accepted)

• The deadline to be listed in the Attendee Directory (distributed on-site) is February 21, 2017.
• The deadline for pre-registration is February 21, 2017 . After that date, plan to register at the conference site.

  * Required information needed to process registration.

Registration Information

First Name*:

Last Name*:

Credentials/Degrees:

Job Title:

Employer/Institution:

Daytime Phone*:

 (include area code)

Fax:

 (include area code)

The following mailing
 address is*:

Home:   |    Company/Affiliation:

Address*:

Address 2:

City*:

State/Province*:

Zip/Postal Code*:

Country:

 (Leave blank if USA)

Email Address*:

 (Required to send confirmation)

ISPN Member Status*:

 

If you chose *Would like to become a Member, please include a completed membership application.

* Includes 3 free months of membership (July 1 - June 30 membership year). Check pricing below.

*
PLEASE NOTE: The option to join ISPN at the time of the Annual Conference is only available to those individuals who have never belonged to ISPN. If you were a member in the past and would like to renew and take advantage of the member discount for registration, please contact the ISPN membership department at info@ispn-psych.org or +1-608-443-2463 or renew online.

Be a Member...
Bring a Member:

Were you referred by an ISPN member?  Yes    No
If yes, please include the member’s name:

Exclude from Directory:

 Check here if you do NOT wish to be listed in the conference attendee directory which is
     distributed to exhibitors and attendees. The deadline to be listed in the Directory is
     February 21, 2017.

Emergency Contact:

Please provide contact information of the nearest relative or friend in case of emergency
Name: 
Daytime Phone:

Special Needs:

An ISPN staff member will contact you for more details.

Badge Information

Please complete only those lines that are different from the information under “Registrant Information”, above.
(This is the information that will display on your badge.)

First Name or Nickname:

Full Name:

Place of Employment:

City:

State/Province:

Country:

Faculty/Student Involvement

ISPN would like to recognize any faculty members who encourage students to attend the ISPN Annual Conference. If you are a faculty member bringing students with you to the 2017 Annual Conference, please check the box and indicate your students’ names.

    I am a faculty member bringing students to the 2017 Annual Conference. If Yes, please fill in the school and student names.

School:

Student Names: 

ISPN Psychopharmacology Institute - Tuesday, March 7 and Wednesday, March 8, 2017
The deadline for pre-registration is February 21, 2017. After that, plan to register at the conference.

ISPN Member

$300 USD

Non-Member

$350 USD

Student 

$125 USD

Clear Above Selection:

Students : You must also fax or mail a copy of your student ID to the address at the top of this page

 

ISPN Annual Conference - Wednesday, March 8 to Saturday, March 11, 2017
The deadline for pre-registration is February 21, 2017. After that, plan to register at the conference.

 

Register on
or before 1/31/17

Register
after 1/31/17

 

ISPN Member

$470 USD

$520 USD

 

Non-Member
(Join now and get member pricing! See details)

$620 USD

$670 USD

 

Joining ISPN with the Conference*
(See requirements)

 

$595 USD

$645 USD

 

Student 
(Fax or mail a copy of your student ID to the address at the top of this page)

$175 USD

$225 USD

 

One Day Registration - ISPN Member
(Select a day below)

$275 USD

$325 USD

 

One Day Registration - Non-Member
(Select a day below)

$325 USD

$375 USD

 

 Thurs  |  Fri  |  Sat  |  Clear “Day” Selection

Clear Above Selection:

 

Membership Renewal

ISPN Members Renew your membership (July 1, 2017 through June 30, 2018)
             
Full $150  |  Student $25  |  Retired $60  |
Clear Selection:

Registration Discounts
(You must be a lead presenter to qualify for a discount. Only ONE discount is allowed per registrant.)

This discount will be reviewed for eligibility prior to acceptance of your conference registration.

Please check the following box that is applicable to your registration fee.

 

Psychopharmacology Institute Lead Presenter - Concurrent Session ($50.00)

 

Annual Conference Lead Presenter - Concurrent Session/Workshop Leader ($50.00)
You must register for the entire Annual Conference to receive the above discount.

 

Annual Conference Lead Poster Presenter ($25.00)
You must register for the entire Annual Conference to receive the above discount.

 

Clear above selection:

 

ISPN Foundation Event

Reception and Auction at the Baltimore Marriott Inner Harbor at Camden Yards
The annual reception and auction will be held on March 9, 2017, from 6:15 p.m. to 8:15 p.m.
This year’s event will feature light hors d’oeuvres and cash bar (One drink ticket will be provided).

A silent and live auction will take place to raise funds to support scholarships to assist graduate students
and international members, research grants, endowment for the Foundation, and ISPN sponsored events.

Thursday evening, March 9, 2017  •  Tickets are $50 per person.

Number of participants for the ISPN Foundation Event

 

 

Nursing Contact Hours

Yes!  I would like to receive nursing contact hours (if yes, you must fill in the following): 

    State Licensed in: 
    License Number:   (required)

 

No, I do not wish to receive nursing contact hours

 

 

 

Charitable Donation

If you are interested in making a donation to ISPN, select one button under amount and one button under donation type.

 

 

Donation Type

 

 

By checking this box, you are pledging a total of $500 to the ISPN Foundation

 

 

 New Lamplighter Commitment ($100.00 for 5 years - $500 total donation)

 

 

 Payment to existing Lamplighter Commitment

Amount

 

 

$25.00

  General Contribution

 

$50.00

  Mental Health and Wellness Research Scholarship

 

$100.00

  Carol Williams Memorial Scholarship Fund

 

$200.00

  Susan McCabe Lecture Fund

 

$300.00

  ISPN Foundation

 

$500.00

  Greatest Need

 

$1000.00

 

 

 

 

 

 Other Amount  (Please, whole dollars only, e.g. 35)

 

Clear above selection

  Clear above selection

ISPN Foundation is a 501 ( c ) 3 non-profit organization. Donations are tax deductible according to state law.

 

(You will be able to verify all the information on the next page before submitting your registration.)

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