DIVISION OF CONTINUING EDUCATION REGISTRATION FORM

New York 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 Zip Code City State Zip Code

Phone: ( )_____________________________ Phone: ( )_____________________________

E-mail: ____________________________________ E-mail: _____________________________________

(If different from present address)

In case of emergency, notify: _______________________________ Relationship:_____________________

Day Phone: ( ) _______________________ Evening Phone: ( ) _______________________

Cell Phone: ( ) ________________________ Email: _____________________________________

Available housing at New York University has two single beds per bedroom; therefore, you must have
a roommate. (If you do not list a roommate by April 23rd, a roommate will be randomly assigned.)

Roommate: ____________________________________________________________________________

Housing/Program fee: $2,850.00 (may be paid in three installments: 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 $75)

Payable by credit card - $2,850 or 3 installments 3/26, 4/9, & 4/23

plus credit card fee of $65 – check or cash only

Payable by check $2,850 or 3 installments 3/26, 4/9, & 4/23

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: New York 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!