Registration Form
Workshops, Institutes, and Seminars

Name: Last  
School District:
Job Title:
City State Zip
Telephone: Day  
Fax Number:  

Title of Training:
Date of Training:

Classroom Teacher/Grade University Faculty/Staff
Certified School Support Staff
Administrator-School Campus Head Start Center
Administrator-Central Office Other

SEMI Credits Contact Hours

Method of Payment:

You must click on "Submit Form" below to send your Application for admission to the College of Lifelong Learning at Jackson State University. Please verify all information before sending. By sending this application you are certifying that the information hereon is complete, accurate and true to the best of your knowledge. Misrepresentation of facts hereon will be cause for refusal of attending.