Online Registration Form

Midwestern State University
Continuing Education
Registration Form

Date:

First Name:      Middle Initial:      Last Name:

Address:

City:       State:       Zip Code:

Phone:       Email Address:

Place of Employment (optional):

Your name as you want it to appear on your certificate:




Courses for which you would like to enroll (course name and date):

1.
2.
3.
4.
5.




YOUTH (AGE 12 AND UNDER)

Youth Name:

Age:       Date of Birth:

Consent Form (Required for all youth): Parent or Legal Guardian must visit the office of
Continuing Education to sign a consent form before the registration will be complete.




I have special needs

* For credit card payment arrangements, please call our office at the number listed below.

** Please make checks or money orders out to "MSU Center for Continuing Education." **
If you are unable to submit this form electronically or want to include a check or money order
for registration & fees payment, please print this form, fill it out, and mail it to:

MSU Center for Continuing Education
Midwestern State University
3410 Taft Blvd.
Wichita Falls TX 76308

OFFICE HOURS: Monday-Friday, 8am-5pm
OFFICE LOCATION: Hardin Hall North, Second Floor, Room 215
Telephone: (940)-397-4756
FAX: (940)-397-4052