Midwifery Today Conference
“Autonomous Midwifery: The Key to the Future”
Blankenberge, Belgium • 30 October – 3 November 2013
Registration Form

1. Name and Address

Please print.

First Name / Given Name	Last Name / Surname	Name to appear on badge (if different)

Street Address / P.O. Box	City

State / Province / Region	ZIP / Postal Code	Country

Telephone	Fax	E-mail Address

How are you involved in birth?

How many births have you attended? _________

How did you hear about this conference?

What excites you about this conference?

Do you give permission for Midwifery Today to release your name and address to fellow registrants?

2. Class Selection

I will attend classes on these days (select all that apply):

Please tick off each class you will attend. Select one class from each set of concurrent sessions offered on the days you will attend. For example, if you will attend the conference on Friday, you need to select one class from C1 through C5 and also one class from D1 through D5. Class descriptions can be found in the conference program.

Wednesday, 30 October 2013 : Pre-Conference

Thursday, 31 October 2013 : Pre-Conference

Friday, 1 November 2013 : Day One

Saturday, 2 November 2013 : Day Two

Sunday, 3 November 2013 : Day Three

3. Subscribe to Midwifery Today  [ Optional ]

Midwifery Today is an English language publication, published four times per year. Each issue contains 72 pages of articles, stories, and opinions, written by midwives and other birth practitioners from around the world.

Address	Price for 1-year subscription to Midwifery Today
United States	U.S. $55	---	---
Canada / Mexico	U.S. $68	---	---
International	U.S. $75	€55	£45

If you would like to subscribe to Midwifery Today, please select the appropriate box below and enter your subscription price in the Payment section of this form.

4. How to Determine Conference Prices

1. Prices do not include meals, transportation or overnight accommodations. Look up your price in the table in Section 5.

2. By registering early, you become eligible for reduced conference prices. The early registration deadlines are 17 June 2013 and 15 August 2013. Prices are shown in the table in Section 5 for each deadline. Payment must be made by deadline to be eligible for reduced prices.
    
   Conference prices are determined by the postmark date on your registration. If you submit your registration by telephone, fax or e-mail, the postmark date will be deemed to be the date that Midwifery Today receives your communication. Payment must be made by the deadline to be eligible for reduced prices.
    
   Walk-in registrants pay the price listed in the table for 7 October when they arrive at the conference.
    
3. If you are eligible for one of the special discounts described below, tick the appropriate box and adjust the prices as directed.
    
   Discounts
    
   

   10% Subscriber Discount

   If you are a subscriber to Midwifery Today, you may deduct 10% from your conference price. Subscription may be started at time of conference registration, but must be current at time of registration to qualify for discount. Midwifery Today magazine is an English language publication. Student discount does not apply to subscription prices.

   20% Student Discount

   If you are a full-time student, you may deduct 20% from your conference price. You must register for three or more days; and you must submit, with your registration, proof of full-time student status.

   If you qualify for a discount, please select the appropriate box below and enter the amount of your discount in the Payment section of this form.

   Subscriber  [ 10% ]

   Full-time student  [ 20% ]

   Subscriber and full-time student  [ 30% ]

4. Prices are subject to change in the event of large currency fluctuations. Prices shown in the table below are current prices.

5. Conference Prices and Payment

Attendance	Conference prices when your registration is postmarked on or before…						Conference prices when your registration is received in-office by 7 October 2013; please do not mail registrations to be received later than this deadline.
	17 June 2013			15 August 2013
1 day	U.S. $150	€120 †	£95 †	U.S. $160	€130 †	£100 †	U.S. $170	€140 †	£105 †
2 days	U.S. $300	€240 †	£190 †	U.S. $320	€260 †	£200 †	U.S. $340	€280 †	£210 †
3 days	U.S. $400	€320 †	£250 †	U.S. $425	€345 †	£265 †	U.S. $450	€370 †	£280 †
4 days	U.S. $550	€440 †	£345 †	U.S. $585	€475 †	£365 †	U.S. $620	€510 †	£385 †
5 days	U.S. $590	€480 †	£380 †	U.S. $630	€520 †	£400 †	U.S. $670	€560 †	£420 †
† Please select the price in U.S. dollars when you pay by credit card.

Walk-in registrants are welcome, but you should check with Midwifery Today to learn the availability of classes. When you arrive at the conference, simply pay the price listed in the table for 7 October.

Please calculate the amount you need to pay by completing the items below.

Enter your conference price from the table above.
If you qualify for a discount (see the Discounts section above), enter the amount of your discount (multiply your conference price by 10%, 20% or 30%). Enter 0 if you do not qualify for a discount.
Subtract your discount from your conference price.
If you are subscribing to Midwifery Today (see the Subscription section above), enter your subscription price. Enter 0 if you are not subscribing at this time.
Add the items above to calculate your total payment.

How will you make your payment? NOTE: Credit cards will be charged in U.S. dollars.

Payment by Cheque

If you pay by cheque or money order, make it payable to Midwifery Today. Payment may be made in sterling, Euros or U.S. funds.

Payment by Credit Card

All credit cards will be charged in U.S. dollars at the listed U.S. prices. We cannot make any guarantee of exchange rate. All fees for fund conversion are the responsibility of the payer.

Payment by Bank Transfer using Euro prices from table

Midwifery Today, Inc., account at:

HSBC Bank plc, 60 Queen Victoria St, London, EC4N 4TR England
Account number: GB06 MIDL 4005 1557 1644 96
BIC code: MIDLGB22

Important: Include registrant name(s) with funds transfer.

Note: The sender is responsible to pay any bank fee charged for the transfer.

Payment by Bank Transfer in sterling

Please e-mail admin@midwiferytoday.com for details.

Refunds

No refunds will be given after 13 September 2013. A processing fee equal to 30% of the amount paid will be deducted from any refund given on or before this date.

Form for Credit Card Payment

Please complete the following items if you are paying by Visa or MasterCard.

Amount to be charged to your credit card in U.S. dollars
Account number (Visa/Mastercard)* *Must be 16-digit number starting with a “4” or “5”
Expiration date  [ month / year ]
Name as it appears on the credit card  [ please print ]
Billing address if different from above  [ please print ]
Billing phone and/or e-mail address  [ please print ]
Signature

6. Information

How to Submit Registration and Payment

1. Please read and complete all of this form. Then make a photocopy for your records.

2. You may mail this form with your payment in sterling, Euros or U.S. funds to Midwifery Today. If you pay by credit card or bank transfer, you may fax this form to Midwifery Today. You may also register by phone or e-mail. (Do not send credit card details by e-mail.) Use the Contact Addresses and Telephone Numbers at the bottom of this form.

3. Registrations must be received in office at Midwifery Today no later than 7 October. If you cannot mail your registration early enough for it to be received prior to this deadline, please register at the conference.

Location of Conference/Hotels

Please see information on location and accommodations on our Belgium gateway page.

Continuing Education

A certificate of attendance will be provided to each participant. No U.S. CEUs will be provided.

Contact Addresses and Telephone Numbers

Midwifery Today
P.O. Box 2672
Eugene, OR 97402-0223
U.S.A.

conference@midwiferytoday.com
1-800-743-0974  [ U.S. and Canada only ]
+1 541-344-7438
+1 541-344-1422  [ fax ]

Conference Updates

Up-to-date conference information can be found on the Midwifery Today Web site:

www.midwiferytoday.com/conferences/Belgium2013/updates.asp

Disclaimer

Midwifery Today, Inc., cannot be held responsible for natural disasters, labor strikes, acts of war or other events that may cause the conference to be rescheduled. Midwifery Today, Inc., reserves the right to postpone the conference to another time, date and if necessary, location. In the event of a conference postponement no refunds will be issued. Registrants can transfer their fees toward any other Midwifery Today conference.

Midwifery Today, Inc., reserves the right to substitute teachers and/or classes. The views and opinions expressed by teachers are their own and may not represent the views and opinions held by Midwifery Today, Inc., and its staff members.