2024 OHIC National Conference

Prefix:

Please add your prefix.

First Name: *

Please add your first name.

Last Name: *

Please add your last name.

Credentials / Suffix:

Job Title: *

Please add your job title.

Agency: *

Please add your agency.

Street Address: *

Please add your street address.

Apt / Suite:

City: *

Please add your city.

State / Territory: *

Please add your State / Territory.

Zip Code: *

Please add your zip code.

Work Phone: *

Please add your phone number.

Cell Phone:

Email: *

Please add your Email address.

Program: * (select all that apply)
SMP
SHIP
MIPPA
ACL
SHIP TA Center
SMP Resource Center
MIPPA Resource Center
Other

Name Badge Information:
Registration information will be used to create your conference name badge. We include first name, last name, state, and program. If you require adjustments, please let us know.

ADA Accommodation Requirements:
(Wheelchair or other assistance)