8th Annual Health & Wellness Day Conference Registration Form - Special Needs in My City

8th Annual Health and Wellness Registration Form

STEP 1: Enter Your Information

I am a…(Required)

I am a…(Required)

Please tell us your role in our beautiful SNIMC community:

Name(Required)

Email(Required)

Mailing Address(Required)

Apt/Suite

City(Required)

State(Required)

Zip Code(Required)

Contact Phone Number(Required)

Is this your first time at our Health and Wellness Conference?(Required)

Yes

No

Number of individuals with special needs in household(Required)

Please enter a number from 0 to 5.

Child 1: Birth Year(Required)

Please enter a number from 1924 to 2026.

Child 1: Disability(Required)

Please list Child 1's disability/disabilities.

Child 2: Birth Year(Required)

Please enter a number from 1924 to 2026.

Child 2: Disability(Required)

Please list Child 2's disability/disabilities.

Child 3: Birth Year(Required)

Please enter a number from 1924 to 2026.

Child 3: Disability(Required)

Please list Child 3's disability/disabilities.

Child 4: Birth Year(Required)

Please enter a number from 1924 to 2026.

Child 4: Disability(Required)

Please list Child 4's disability/disabilities.

Child 5: Birth Year(Required)

Please enter a number from 1924 to 2026.

Child 5: Disability(Required)

Please list Child 5's disability/disabilities.

Organization Type(Required)

Name of Organization(Required)

Organization Mailing Address(Required)

Organization Mailing Address: line two

City(Required)

State(Required)

Zip Code(Required)

Job Title(Required)

Name of School / Agency(Required)

Mailing Address of School / Agency(Required)

Apt/Suite

City(Required)

State(Required)

Zip Code(Required)

How did you hear about us?

We welcome you to SNIMC!

Comments

How can we help your company/organization?

STEP 2: Purchase your tickets!

Your ticket includes breakfast and lunch buffet

Early Bird Special: $49 (Save $30 -Early Bird Pricing!)

Be one of the first 30 to register by October 11th and get a $15 Target or See’s Candies gift card!
Don’t miss out, Limited to the first 30 sign-ups! (one gift card per attendee who signs up by Oct. 11th )

Starting Oct. 12: $59 At the Door: $79

Livestream will take place 9:30 AM – 3:15 PM PDT on November 8, 2025

Livestream Tickets: $20 per person

STEP 3: Select your ticket quantity

Please enter the total number of tickets you need including any guests that will be accompanying you.
If you are bringing more than 5 guests, please contact meenat@snimc.org
Cancellation: Please note that completing registration is a formal commitment to attend. Registrations are non-refundable after 48 hours, as your gourmet meals will be ordered upon registration.

Total Number of Tickets Needed:(Required)

How many total head sets do you need for Spanish Interpretation at the conference?(Required)

Please add guest#1 details(Required)

First Last

Please add guest#2 details(Required)

First Last

Please add guest#3 details(Required)

First Last

Please add guest#4 details(Required)

First Last

Price Per Ticket: $49(Required)

Price: $ 49.00

Total

Credit Card(Required)

Card Details

Cardholder Name