Please complete the following information and then left-click your mouse on the "Submit" button at the bottom of this form.

Last Name:    First Name:

School: Select from Below: Collinsville H.S. Cor Jesu Academy Crystal City H.S. DeSmet Jesuit H.S. Gateway Institute of Tech. Hazelwood Central H.S. Hazelwood East H.S. Kirkwood H.S. Lindbergh H.S. Maplewood-R.H. H.S. Marquette H.S. Metro H.S. Nerinx Hall H.S. Notre Dame H.S. Parkway North H.S. Riverview Gardens H.S. Rosati-Kain H.S. St. Joseph's Academy St. Louis University H.S. Soldan Internat'l Studies H.S. University City H.S. Ursuline Academy Vashon H.S.    Graduation Year: Select from Below 2002 2003 2004 2005

Home Address:

City:    State: Select IL MO    Zip Code:

Home Phone:     Cell Phone:    E-Mail:

Which country would you like to represent? (You will be notified about your assignment)

1st Choice:      2nd Choice:

3rd Choice:

Please check your 1st, 2nd, and 3rd choice for committee assignments:

OR, would you like to take on a special role?  If so, please check one or more:

  Journalist     U.N. Charter Specialist:

Do you want vegetarian meals: Select Yes No

Please indicate any other participants who you would like as hotel roommates (list up to three):

For full-paying students, a $60.00 fee must be submitted to Civitas Associates by January 7, 2001.

  Check if you would like financial assistance for the conference.

If you have questions, E-Mail us as [email protected] or call us at (314) 367-6480.