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To register, print this page, complete form and return to:
Dr. Stam M. Zervanos
Penn State University
Berks-Lehigh Valley College
P.O. Box 7009
Reading, PA 19610
Deposit: A check in the amount of $500 payable to
Penn State University must accompany registration.
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Name
Last :_________________________________________________________________
First:_______________________________________ Middle Initial:_________
Social
Security #:_____________________________ Date of Birth: ______________
Parent or Guardian: ___________________________________________________
Home Address
Street:________________________________________________________________
City:_________________________________ State:____ Zip:________________
Campus _______________________________________________________________
Address _______________________________________________________________
E-mail Address:________________________________________________________
Phone Number
Home: (______)____________________ Campus: (______)____________________
ACADEMIC INFORMATION
University now attending (if any):_____________________________________
_______________________________________________________________________
Major:_________________________________________________________________
Semester Standing:_____________________ Current GPA:___________________
I will participate as: (circle one)
*Biology 297 *Biology 497 **Non-student
Roommate preferences:__________________________________________________
* Space for each option is limited and will be assigned based on current academic standing.
** Space for this option is limited and will be assigned on a first-come basis.
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Overview