Registration

Event:
Start Date/Time: End Date/Time:
Fee per Student: Room:
* - denotes required fields
Family Information
First Name:* Last Name: *
Type*
Home Phone: Click to Enter an International Number Cell #: Click to Enter an International Number Work #: Click to Enter an International Number
Email:* (Emails are kept confidential)
 
Address: *
City: * State: * Zip: *
Emergency Contact Info
(Not Contact #1 or #2)
 
 
Students entered below will be added to your family's account
 
Questions/Options:
Do you want to include a meal plan at the UIC cafeteria for breakfast and dinner for Thurs thru Sunday for $68 extra? (Lunch is served at CITY each day)*
Do you want internet access to your room for $10 extra?*
 
Additional Information:
 
 
Other Questions/Comments:
 
Credit Card Verification:
   
Card Number: *  
Name as it appears on card: *
Nickname:
Card Expiration Month: *   Exp Year: *
Address Line 1: Address Line 2:
City: State: Zip:*