Spring Hat-titude Day Registration Form

Name ___________________________________________________________________________

Chapter Name ____________________________________________________________________

Address _________________________________________________________________________

City/State/Zip ____________________________________________________________________

E-mail Address ____________________________________________________________________

Birthdate _________________________________ Home Phone ____________________________

Work Phone _______________________________

Method of payment (check one):
Check (made payable to SCC)      MasterCard      Visa      Discover

Card # ___________________ Exp. Date _________

Name as it appears on card: ______________________________________

Signature_________________________________

Mail form and payment to:

St. Charles Community College
Attn: HUM 103
4601 Mid Rivers Mall Drive
Cottleville, MO 63376