Payment Form – 2016 Kansas WIC Conference

March 29-30, 2016 – Topeka

Agencies and individuals should use this form to process payment.

List multiple persons, or if preferred, use a separate form for each person.

This is not a registration form. Each person must register through Kansas TRAIN. http://ks.train.org

Full registration information is provided when registering for Kansas TRAIN, or on the Kansas WIC website Training page http://www.kansaswic.org/local_agencies/training.html

(You can find the following on the webpage: Registration information, draft agenda, tips for using Kansas TRAIN, and payment form.)

·  Contact Patrice Thomsen about problems with registration, late payment, special accommodations or other questions. (785) 296-1189 or

·  Fee is $75 for WIC and $125 for non-WIC staff. Fee includes conference materials and meals/breaks as indicated on agenda.

·  Payment may be made by check or credit card. Complete both pages of this Payment Form. Mail form (and check, if applicable) to: Patrice Thomsen, KDHE/Nutrition & WIC Services, 1000 SW Jackson, Suite 220, Topeka, KS 66612

o  If paying by check: Make checks payable to Kansas Department of Health and Environment. Receipts will be sent for personal checks or by specific requests.

o  If paying by credit card: Mail this completed form to above address or scan and email to .

·  Payment is preferred by the conference date, but late payments may be arranged by notifying Patrice. Do not delay registering on KS-TRAIN to wait for your payment to be sent!

·  Cancellations received prior to March 21 will be refunded. Cancellations received after March 21 will not be refunded and will be billed if not paid. Staff substitutions may be made any time.

Name of WIC Agency/Other Organization: ______
Name / WIC Staff?
Yes / No / Name / WIC Staff?
Yes / No

Kansas Department of Health & Environment

Payment by Credit Card for Event Registration

Registrant Information

Organization Name (if applicable):
Name/s: / (List registrants on Page 1)
Address:
City: / State:
Zip Code: / Telephone:
Email Address:

Event Details

Description: / 2016 Kansas WIC Conference
Date of Event: / March 29-30, 2016 / Cost: $75 for WIC staff;
$125 for non-WIC staff
Location of Event: / Topeka

Payment Information

# WIC Staff ___ x $75 = $______
# non-WIC Staff X $125= $______
Total paid = $______
  Check made payable to: Kansas Department of Health and Environment
  Credit Card

Discover MasterCard VISA / Cardholder Name:
Card Number:
Expiration Date:
I agree to pay the above total amount according to the card issuer agreement.
Authorized Signature: ______Date: ______

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