Registration for Mark Twain Teachers' Workshop Please fill out all fields on this form! Name(Required) First Middle Last Do you have other names appearing on high school/college transcripts? Social Security Number Home Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Main Phone(Required)Do you have an additional phone number?Email(Required) Current Place of Work(Required) Work Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Date of birth(Required) MM slash DD slash YYYY Birthplace (City and State) Racial/Ethnic InformationTo comply with Title VI and Title IX of the Federal Government regulation, we must have the following information.I am:(Required) Black Non-Hispanic American Indian or Alaskan Native Hispanic Asian or Pacific Islander Whit Non-Hispanic Non-Resident Alient Other Are you a U.S. citizen?(Required) Yes No Gender:(Required) Male Female Religious Preference(Required) Have you ever attended Hannibal-LaGrange University?(Required) Yes No If you answer is yes, what was the last date you attended?(Required) In this section, please record all instances of previous higher education. Include the college/university name, city/state of the institution, dates attended, and degree. Separate multiple institutions with a paragraph break in between.(Required)Please note, in order to complete your registration, you must contact the HLGU Business Office to pay a $300.00 tuition charge. Contact the Office at email@example.com or 573-629-3055.