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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