DIVISION OF CONTINUING EDUCATION REGISTRATION FORM

Chicago Studies Program

Department of Radio-Television, Department of Cinema & Photography, and School of Journalism - Summer 2010
(Please print, sign, and return with your payment of the program fee):

Name: _____________________________
(First ) (MI) (Last)

Present Address: (Good until_____/_____/_____) Permanent Address:

_________________________________________ ___________________________________________
Street Address Street Address

_________________________________________ _________________________________ _________

Street Address (continued) Street Address (continued)

_________________________________________ __________________________________________
City State Zip Code City State Zip Code

Phone: ( )_____________________________ Phone: ( ) _____________________________

E-mail address: ____________________________ E-mail address: ____________________________

(if different from present address)

In case of emergency, notify: _____________________________ Relationship: ______________________

Day Phone: ( )__________________________ Evening Phone: ( )__________________________

Cell Phone: ( )__________________________ Email: ________________________________________

Payment by check: Make check payable to: SIUC in the amount of $250 Check #: _________
Due March 26, 2010
Payment by credit card:

Credit card #: _____________________________ Exp. Date: __ ______________

Name on Card: ____________________________ ________________________________________

Authorized Signature: _ ______________________ ________________________________________

Mail or bring form to: Chicago Studies, Jackie Welch, Division of Continuing Education, Washington Square,
Building C, MC 6705, Southern Illinois University, Carbondale, IL 62901

This form must be returned to Continuing Education with your payment of the program fee!