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Mission u Registration
Mission u 2019
July 26-28, 2019
Central Methodist University
Fayette, MO
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* Indicates required question
Email
*
Your email
Note: Email address provided above will be used for sending confirmation letter
Please provide the following information for the person being registered
First Name
*
Provide name as you would like it to appear on name tag
Your answer
Last Name
*
Provide name as you would like it to appear on name tag
Your answer
Gender Identity
*
Male
Female
Other:
Mailing Address - #
*
Number and street, PO Box #, etc.
Your answer
Mailing Address - City
*
Your answer
Mailing Address - State
*
Your answer
Mailing Address - Zip Code
*
Your answer
Primary Phone #
*
Your answer
Alternate Phone #
Your answer
Church
Your answer
District
Gateway Central
Gateway Regional
Heartland
Mark Twain
Mid-State
Northwest
Ozarks
Southeast
Southwest
None of the above
Clear selection
Special Needs
Wheelchair
Walker
No Stairs
Dietary (describe details below)
Special Dietary Needs
Your answer
Name of Emergency Contact #1
*
Your answer
Phone # of Emergency Contact #1
*
Your answer
Name of Emergency Contact #2
Your answer
Phone # of Emergency Contact #2
Your answer
Are there any physical, health, medication, emotional or behavioral concerns we should be aware of to better prepare for your time at Mission u?
*
Yes
No
If yes, what is it and what can we do to help address the situation if it occurs? (Note: this information will be kept in confidence and shared only with those having a need to know; e.g. your study leaders, dean, assistant dean.)
Your answer
Allergies/typical reactions/concerns
Your answer
Do You Want Computer or Internet Access?
*
Yes, Wireless (personal computer, cell phone, tablet)
Yes, Wired (University computer access)
No
Required
Type of Registration
*
Adult/Young Adult
Youth/Child/Childcare
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