Disney Registration Application



Central Michigan University --- Disney College Program

GUEST REGISTRATION FORM

(For students who are not currently attending CMU)

Recreation Fieldwork Credit Program

Name: ___________________________________________________________________________________________________

Last First Middle Initial

Permanent Address:_________________________________________________________________________________________

_________________________________________________________________________________________________________

City State Zip County

Home phone: ( __ ) _____________________________________ Cell phone: (________) ____________________________________

Email: _______________________________________________________________________________________________________________

Note: Please list an e-mail address that will be valid for use during your experience.

Emergency Info (parents): __________________________________________________ Phone: _____________________________________

Social Security Number: ____________________________________________________ Sex: male_______ female_______

Birthdate: ________/_________/_________ Birthplace: city/state_____________________________________________________________

Ethnic/Racial Background: _____African American _____Asian _____Caucasian

_____Hispanic _____Native American Indian

High School attended: _______________________________________City___________________________State_______Grad Date ____/____

Month - Yr

HS Attendance dates: from _________/________ to ________/_________ Date of Diploma ______/______

Month-Yr Month-Yr Month-Yr

University/College (currently attending) : ____________________________________________City__________________________State______

Start Date: _______/________ Current GPA: ______________

Month-Yr

Major: ______________________________________________________ Placement Location: Disney World _____ Disneyland _____

Course/Credit Desired: RPL 318 Field Course in Recreation Specialization (1-12 credits ) ________________credit

List # of credits desired

Semester attending Disney Program (check one): _____ Fall 2015 _____ Fall Advantage 2015

_____ Spring 2016 _____ Spring Advantage 2016

Disney job title: ________________________________________________________________________________________________________

Disney Start date: _______________________________________________ End date: ______________________________________________

Payment: _____ check (made payable to “CMU”) 2015-16 Tuition is $290 per credit with additional one time admission fee: $50

_____ credit card 2016-17 Tuition subject to change

Credit card: _____Visa _____Master card _____Discover _____American Express

Card #_____________________________________________________________________ Exp. Date_________

Signature ___________________________________________________________________ Date_____________

Mail/email/fax completed form and payment to: Dean Wallin, Center for Leisure Services, Finch 109,

Central Michigan University, Mt. Pleasant, MI 48859 ---- or fax to: (989) 774-2161

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