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Wallaby 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

Deadline for application: January 1, 2001

Announcement of acceptance: January 15, 2001

Deposit: A check in the amount of $500 payable to
Penn State University will be required upon
notification of acceptance.

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

Airport preference: (circle one)
  Allentown       Pittsburgh
                  
Roommate preferences:__________________________________________________

Please state why you wish to take this course and how it will benefit 
your career goals: ____________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

* 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.

This page was last updated on November 8, 2000.