Requested Fields:

Yes, I am interested in participating in the Civitas U.N. Simulation for "Grown-ups!"

I would like tickets at $15.00 each.

I would like tables for eight at $80.00 each.

I am registering for myself and [list all other persons]:

Last Name:     First Name:

Address:

City:     State: Select: IL MO Other   Zip Code:

Home Phone: (xxx) xxx-xxxx
Work Phone: (xxx) xxx-xxxx    Extension:
Cell Phone:    (xxx) xxx-xxxx

E-Mail #1:    
E-Mail #2     

I am:

Civitas alumna or alumnus
Parent of High School student(s) in Civitas activities
Parent of Middle School student(s) in Civitas activities
High School Faculty Advisor
Middle School Faculty Advisor
Friend of Civitas

I [We] would like to represent the following country or countries. [One country per delegate.  As many as 8 countries per table of 8.  Partners or small groups may share a country.  Delegates may select countries at the door, from those not previously reserved.  To reserve a country, you must pay in advance.]

[1st Choice:]                     [2nd Choice]

[3rd Choice]                     [4th Choice] 

Optional Fields:

I became interested in Civitas because of:

Occupation:

School or work affiliation (if applicable):

I am interested in:

Adult Activities (Simulated U.N., speakers, issue forums, etc.)
Assisting students in research [area(s) of special knowledge:
Making a tax-deductible contribution to Civitas
Other volunteer activities (e.g. helping with event registration, providing refreshments, driving, etc.)
Researching material for Civitas activities

Thank you very much.  Please click the "Submit" button below.