Registeration Form
Workshops, Institutes, and Seminars
Name:
Last
First
School Name:
School District:
Job Title:
Email:
Social Security:
Address:
City
State
Zip
Telephone:
Day
Evening
Fax Number:
Gender:
Male
Female
Title of Training:
Date of Training:
MM/
DD/
YYYY
Please check one:
Classroom Teacher/Grade
University Faculty/Staff
Certified School Support Staff
Support Staff
Administrator-School Campus
Head Start Center
Administrator-Central Office
Other
Please check one:
Continuing Education Units (CEUs)
Social Worker Units (SWUs)
SEMI Credits
Contact Hours
Method of Payment:
Check
Purchase Order#
Money Order
You must click on "Submit Form" below to send your Application for admission to the College of Lifelong Learning at Jackson State University. Please verify all information before sending. By sending this application you are certifying that the information hereon is complete, accurate and true to the best of your knowledge. Misrepresentation of facts hereon will be cause for refusal of attending.