Registration form and $200 non-refundable deposit due by July 1, 2000,
to guarantee enrollment.
NAME:___________________________________
STREET ADDRESS:_____________________________
APT:________________________________________
CITY:_______________________________________ STATE:_____ ZIP:_______
AGE:_____ BIRTHDATE:________________
SUMMER PHONE:(____)__________________
UNIVERSITY AFFILIATION:_____________________
SOCIAL SECURITY NUMBER:______-____-_________
BIRTHDATE:____/____/____
NUMBER OF SEMESTERS IN:
COLLEGE TEAM DEBATE:_____ COLLEGE LD:_____
COLLEGE PARLI:_____
HIGH SCHOOL TEAM:_____ HIGH SCHOOL LD:_____
PLEASE INDICATE ANY MEDICAL PROBLEMS (ALLERGIES, MEDICATIONS,
INJURIES):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
MAKE CHECKS PAYABLE TO MTSU
_____ $200 deposit, with remaining $650 due at check-in
_____ $850 full payment
FOR CREDIT CARD PAYMENTS:
I hereby authorize my credit card in the amount of $_________
for ______________________ charges. Date:___________________
Student's name (please print):_______________________________
Student's Social Security No.:____-____-_____
CARDHOLDER'S Name __________________________
CARDHOLDER'S Address _____________________________
CARDHOLDER'S City, State, Zip
_____________________________
CARDHOLDER'S Daytime Phone _____________________________
CARDHOLDER'S Signature is
required__________________________
Check one: _____ Visa _____Mastercard
Card Number:_____________________ Exp. Date:_________________
Return to:
Mid-South Debate Institute
c/o Dept of Speech and Theatre
Middle Tennessee State University
Murfreesboro, TN 37132
Phone: (615) 898-2640
Fax: (615) 898-5826