MDH Event Payment Form

Instructions

If the event/course title is not preselected, select it from the Event Title dropdown.
Select a payment type (a convenience fee may be charged at time of payment)
- Individual: Checking/Savings OR Credit/Debit Card
- Group: Checking/Savings OR Credit/Debit Card (Multiple persons register with one payment)
Enter registrant information and click Submit. An opportunity to add payment contact information is provided on the payment screen.
- Important Note: For events/courses available through the MDH Learning Center, all registrants must begin the registration process using that system and receive an email stating their enrollment is pending payment before submitting payment using this form.
After a successful credit card payment to US Bank the payer will receive an email confirmation. If paying by "Group: Credit Card", each member of the group will receive a separate email confirmation.

If you have questions about the event or payment, contact the program coordinating the event. For problems with this form, contact Health.LMS@state.mn.us.

Event/Course Information
Event Title:
Event Description:
Event Fee:

Registrant Information *( = Required Field)**
Payment Type *: Individual: Checking/Savings OR Credit/Debit Card Group: Checking/Savings OR Credit/Debit Card (Multiple persons register with one payment)
First Name*:
Last Name*:
Email Address*:
Re-enter Email Address*:
Phone Number*:	(9999999999) (do not use hyphens or parentheses)
Organization:
Street Address 1*:
Street Address 2:
City*:	State: Zip:
Special Accommodations: (i.e. ASL interpreter or CART services)

Leave this field blank