DIVISION OF CONTINUING EDUCATION REGISTRATION FORM

Hollywood 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/housing fee:
Name: ____________________________________________________ Gender: _____ Male _____ Female
(First)

(MI)

(Last)

Present Address: (Good until_____/_____/_____)

Permanent Address:

_________________________________________

___________________________________________

Street Address

Street Address

_________________________________________

_________________________________ _________

Street Address (continued)

Street Address (continued)

_________________________________________
City

State

Phone: (

Zip Code

__________________________________________
City

)_____________________________

E-mail:____________________________________

State

Phone: (

Zip Code

) _____________________________

E-mail:____________________________________
(If different from present address)

In case of emergency, notify: _______________________________ Relationship:_____________________
Day Phone: (

)_____________________

Cell Phone: (

)_______________________

Evening Phone: (

)_________________________

Email: ______________________________________

Housing/Program fees: 2 bedroom, 4 student apartment: $2,700 or Studio apt.: $4,900 (you can pay in full
or in 3 installments payable on March 26, April 9, and April 23)
(We accept Visa, Discover, MasterCard, check, or cash. If paying by credit card, there will be an
additional charge of $60 for a 2 bedroom, 4 student apartment and $110 for a studio apartment.)


4 bed apartment - $2,700
plus the
Studio apartment - $4,900
plus the
3 Installments 3/26, 4/9, & 4/23








 credit card fee of $60 – check or cash only







 credit card fee of $110 – check or cash only
Paying in full

If selecting the 2-bedroom, 4 student option, please list out selected roommates:
(If you do not list names of roommates by April 23rd, roommates will be randomly assigned.)
Bedroom #1: Student #1 __ __________________

Student #2:

_____________________________

Bedroom #2: Student #1 __ __________________

Student #2:

_____________________________

Payment by check: Make check payable to: SIUC

Check #: ___________ Amount: $_____________

Payment by credit card (If you are paying by credit card, you can pay by phone; call (618) 536-7751.)
Credit card #: ______________________________________________ Exp. Date: ___________________
Name on Card: _________________________________________________________________________
Authorized Signature: _____________________________________________________________________
Mail or bring form to: Hollywood 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 housing/program fee!

Sign up to vote on this title
UsefulNot useful