Title 
  First Name  M.I.  Last Name 
 

Organization 

 

Address 

 
City  State  Zip Code 
 

Email Address 

 

Telephone ( )  -

Method of Payment:

Check (payable to Stillman College)

VISA

Mastercard

 
Registration Fees: $150 (includes conference meals/ Mississippi trip)
  $20 General Public (meals/ trip not included)
  $5 Students with ID (meals/ trip not included)

Payments Should be mailed to:
Stillman College
Emmett Till Conference
c/o Dr. Linda Beito
P.O. Drawer 1430
Tuscaloosa, AL 35403
 
 
 

SPACE IS LIMITED * REGISTER EARLY
Conference Agenda available at www.stillman.edu

EMMITT TILL CONFERENCE
REGISTRATION FORM