The University of Southern Mississippi

The Abbey Summer Programs 2005

June 12 – July 1

Name ____________________________________________________ EmplID ________________

Last First Middle (To be issued by USM)

Social Security No. __________________________

Current Address __________________________________________________________________________

Street City State Zip

Phone (____) ___________________ Email ____________________________________________

Permanent Address _______________________________________________________________________

Street City State Zip

Phone (____) ___________________

The Summer Abbey Course: Humanities in the Heart of France- June 12 – July 1

History, English; International Studies

Summer Abbey Course (please choose one; 3 credit hours)

Memories of the Past

Chateaux, Cathedrals and Cloisters

The Bicycle as Muse

International Studies Required by all Students (1 credit)

Check if you will be requesting financial aid for this program.

Check if you are eligible for a USM faculty/staff dependent scholarship.

Will you be taking any prescription medication during June 2005? Yes No

If so, please inform the director in writing.

Person to be notified in case of emergency:

Name ________________________________________ Phone (____) _________________________

Address ______________________________________ Relationship _________________________

Tuition, Fees, Housing, and Flight

Undergraduate, 4 hours……$3,799.00

Please return completed form and your $200.00 nonrefundable deposit by April 8, 2005 made payable to: USM-The Abbey Summer Program, The University of Southern Mississippi, Box 10047, Hattiesburg, MS 39406-0047. Balance, less deposit, is due no later than April 8, 2005. The balance, less deposit, is refundable if cancellation, in writing, is received prior to April 8, 2005.