Register – The Midwest Clinic

Professional Registration Form

Contact Information

*Company/Institution Name:

*Prefix

*First Name

*Last Name

*Email

*Username

*Password

*Confirm Password

*Street Address

*City

*State/Province

*Zip/Postal Code

*Country

*Mobile

Additional Information

If you are a citizen of the European Union, we will need your consent under the General Data Protection Regulation (GDPR) to collect all registration information.

*Please select ‘Yes, I agree’ to consent to sharing your information.

I am not a citizen of the European Union.

I am a citizen of the European Union and, yes, I agree.

I am a citizen of the European Union and I do not agree and will not register.

*I identify my gender as:

Male

Female

I prefer not to respond

Other

*Age

17 or younger

18 – 20

21 – 29

30 – 39

40 – 49

50 – 59

60 or older

I prefer not to respond

*I identify my race as:

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or other Pacific Islander

White or Caucasian

Bi-Racial

Other

I prefer not to respond

*I identify my ethnicity as:

Hispanic or Latino

Non-Hispanic or Latino

I prefer not to respond

*Please select the level that best describes the majority of the students you teach:

*Please select the label that best represents your professional title:

*Excluding the current year, how many times have you attended The Midwest Clinic? If you are a first-time attendee, please enter the number “0”.

*How did you hear about the Midwest Clinic?

*Please feel free to share my contact information with Midwest Clinic Exhibitors and Sponsors.

Yes

No, thank you.

*Please include me in future Midwest Clinic communications.

Yes

No, thank you.