Stony Brook Southampton
Introduction to Creative Writing
Wednesdays, Sept. 3 – Nov. 19, 2014
REGISTRATION FORM
CONTACT INFORMATION
Date:_____________________
Prefix (circle one): Mr., Ms., Mrs., Dr.
First Name:____________________________ MI:___ Last Name: ___________________________________
Street Address:______________________________________________________________________________
PO Box:_____________________________________________________________________________________
City: _____________________________________________________ State: ______ Zip: __________________
Date of Birth or last four digits of SS#: __________________________________________________________
Email address: ______________________________________________________________________________
Home Telephone #:(_____)_____________________
Business Telephone #: _(_______)________________
Have you ever attended workshops at Stony Brook University, Manhattan or Southampton?
SBU ID is:___________________________
□No □Yes, my
WRITING SAMPLE & PAYMENT INFORMATION
The fee for the 12-week non-credit course is $775, subject to change.
Enclosed please find:
□ five pages of creative writing in any genre
□ a check for $775.00 payable to “Stony Brook University,” check number: __________________
OR
□ a credit card number will be provided on line through the Stony Brook University System, SOLAR. I
understand that I will be contacted by Stony Brook University with directions on how to log into the System and
that I must be paid in full by August 15 to attend the course.
RETURN TO:
Email: Maryellen.walsh-friedmann@stonybrook.edu
Fax: 631-982-7318
Snail Mail:
Attn: Mary Ellen Walsh
Creative Writing & Literature Program
Stony Brook Southampton
239 Montauk Highway
Southampton, NY 11968