MILE
Registration Form
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Fall 2008 Registration 
       Please print off,  fill out and bring or
      mail to MILE with  registration fee of $50 
   
    also see  Becoming a Member

Pending

 

Pending

SPECIAL INTEREST GROUPS

Organized by participants with a MILE Coordinator

 

Pending

                                                 

NAME: ______________________MxCC ID#:_____________

                                         See Name Tag - members only

 

Name tag to read:___________________________________

Address:__________________________________________

City:____________________________  ZIP: _____________

Phone: __________________E-Mail: ____________________

 

 

 

Birth Date____________

    New Member Only

Required of New Members

Soc.Sec.# _______________

 

Mail to:  MILE

Middlesex Community College

100 Training Hill Road

Middletown  CT  06457

 

Method of Payment (Circle One)

Check ($    .00) payable to MxCC

Charge to:  Visa / Master Charge

Account #____________________

Expiration Date _______________