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 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: ______________________________________

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 






 credit card fee of $60 – check or cash only
Studio apartment - $4,900 plus the 






 credit card fee of $110 – check or cash only
3 Installments 3/26, 4/9, & 4/23 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!