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First name

Last name

Address

City

State/Province

Zip/postal code

Country
(if not U.S.)

Telephone

Fax

E-mail


Check one: student professional

If you are a student:

Institution

Degree sought

If you are a professional:

Title/position

Organization

Accommodations: Check the boxes that apply.

Shared accommodation ($4,400)

Preferred roommate's name:

No specific preference. Please assign me a roommate based on the criteria below.

I am: Male Female
My age: 20-40 40-60 60+
I would prefer my roommate to be: Male Female
Preferred roommate's age: 20-40 40-60 60+
Preferred roommate's profession: Student Professional

Single accommodation ($4,850)

Single plus guest ($6,700)

Name of guest:

Please indicate any special accommodation(s) and/or services you require to participate in this seminar:

Special dietary needs (if any):

Academic Credit

I do not plan to take the seminar for credit.

I plan to take the seminar for credit. I understand that the UNC-CH Cashier's Office will charge approximately $250 to cover my credit registration fee. Please send me the application papers to receive credit for the seminar.

After filling out this form, hit the submit button below to review your information. After confirming you have entered the correct information, print a copy for your records and continue on to a secure site to enter payment details.

Thank you for your registration!