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Service 101 Registration

June 25-26, 2014


Student Information

First Name*
Middle Name
Last Name*
Preferred Name
Address*
 
City*
State*
Zip*
Phone* () -
Email*
Confirm Email*

T-Shirt Size:*

High School:*
Intended Major:


Emergency Information

Father's Name
Work Phone () -
Cell/Home Phone () -

Mother's Name
Work Phone () -
Cell/Home Phone () -

Alternate Contact
Relationship
Work Phone () -
Cell/Home Phone () -

Please list any health issues and/or food allergies we should know about:
(i.e. Diabetes, Heart Problems, Seizures, Asthma, Etc.)
**Light to moderate physical/outdoor activity will take place during Service 101.**
 
Contact Information: Office of Recruitment
102 Curris Center
Murray, KY 42071
1-800-272-4MSU ext.2