PARTICIPANT INFORMATION

 

Primary Email:
*

 

An email confirmation will be sent to the email address provided above.

 

Prefix:
First Name:
*
Last Name:
*
Address 1:
*
Address 2:
City:
*
State/Province:
*

If Other (Non US/Canada), please type 00000 in Postal Code.

Zip/Postal Code:
*
Country:
*
Mobile Phone:
*
Work Phone:
Home Phone:
Twitter Name:
Organization/Employer:
*
Job Title:
Secondary/Asst. Email:
Website:
Emergency Contact Name:
*
Emergency Contact Phone:
*
Emergency Contact Email:
CPSI may list my name, company, country and website on the CPSI website and in program book.
*

SPECIAL SERVICE REQUESTS

Please notify us of any special service requests that you require. Special service requests must be made at least 10 business days prior to the start of the event

Under the Americans with Disabilities Act (ADA), I have the following special needs:

Mobility Access to Sessions (e.g., wheelchair, wheelchair accessibility, etc.)
Audio Access to Sessions (hearing impairment)
Visual Access to Sessions

I have the following dietary restrictions/needs:

Dietary Needs:





Dietary Comments:
Critical Allergies:

 

CREATE PASSWORD

Please create a password, which can be used to access and update your registration and to make your program selections and updates.


Password should have minimum 8 characters and at least one number. Special characters should not be used.

 

Password:
*
Confirm Password:
*

 

Next: DEMOGRAPHICS