MEPC Registration Form - Michigan Energy Providers Conference

Type of Registration*
Select Day*
PROMO CODE
Is this your first time attending MEPC?*
- No
- Yes
If this is your first time attending, please enter the name of the person who referred you under "How did you hear about the MEPC?" section below.
How did you hear about the MEPC?
Registrant Information
Name*
First Last
Name on Badge*
Job Title or description*
Organization*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Registrant Email*
Enter Email Confirm Email
Cc Email
Enter Email Confirm Email
Golf Outing
Would you like to register for the golf outing on Thurday 7/25/19?
- Yes. I would like to register for the golf outing.
Name #1 ($130)
First Last
Name #2 ($130)
First Last
Name #3 ($130)
First Last
Name #4 ($130)
First Last
Name #5 ($130)
First Last
Register Additional Guests
*A Registered Guest can attend all conference events such as receptions and meals but are not permitted into the conference sessions. If your Guest would like to attend the conference sessions, they will need to register as a General Attendee.
Would you like to register additional guests?
- Yes. I would like to register additional guests.
Guest #1 ($170) - Name
First Last
Guest #2 ($170) - Name
First Last
Guest #3 ($170) - Name
First Last
Guest #4 ($170) - Name
First Last
Guest #5 ($170) - Name
First Last
Guest #6 ($170) - Name
First Last
Register Children
Would you like to register any children? (17 and under)
- Yes. I would like to register children
Child #1 ($50) - Name
First Last
Age
Child #2 ($50) - Name
First Last
Age
Child #3 ($50) - Name
First Last
Age
Child #4 ($50) - Name
First Last
Age
Child #5 ($50) - Name
First Last
Age

Reception Information
Number Attending Wednesday Reception*
Number Attending Thursday Cocktail Reception*
Would you like to register for Thursday evening's Children’s Program?
PLEASE NOTE: Children MUST BE between the ages of 5-12 and Registered for the Conference in order to participate in the Children's Program.
- Yes. I would like to register for Thursday evening's Children’s Program.
Child #1 ($5) - Name
First Last
Age*
Child #2 ($5) - Name
First Last
Age*
Child #3 ($5) - Name
First Last
Age*
Child #4 ($5) - Name
First Last
Age*
Child #5 ($5) - Name
First Last
Age*

Terms and Conditions
Cancellations: MEPC must be contacted via email or phone by July 8, 2019 to be eligible for a refund. A $25.00 cancellation fee will be applied. No refunds will be made after July 8, 2019.
Media Consent*
Please be aware that by registering for this event, you consent to your image, voice, name, and/or likeness being used, without compensation, on MEPC's website, communications, promotional material, or the websites/ social media of others in attendance, whether now known or hereafter devised, for eternity, and you release MEPC, its successors, assigns, and licensees from any liability whatsoever of any nature.
- Yes, I consent.
- No, I do not consent.
Payment Options
Please select your payment option*
- Invoice my Organization
- Pay by credit card
- *Speaker/Sponsor
Special Needs
Please note any special needs (IE: Accessibility, Dietary requirements)
Questions or Concerns (We will reply)
Emergency Contact
Name*
First Last
Phone*
Email
This field is for validation purposes and should be left unchanged.

Step 1 of 3

Registrant Information

Golf Outing

Register Additional Guests

Register Children

Reception Information

Terms and Conditions

Payment Options

Special Needs

Emergency Contact