To register, print this page, complete form and return to:

Continuing Education
Penn State University
Berks-Lehigh Valley College
P.O. Box 7009
Reading, PA 19610

Last :________________________________  First:___________________________  Middle Initial:_________

Security #:_______________________  Passport #:_______________________  Date of Birth:_____________                             

Home Address
Street:_____________________________  City:___________________________  State:______  Zip:_________

Address:___________________________________________________________  E-mail:_______________________
Home Phone: (_______)_________________________    Campus Phone:  (_______)_________________________


University now attending (if any):_________________________________________________________________

Major:_____________________________________________________ Semester Standing:_____________________     

Check one: Undergrad_____  Grad_____      Check one: Full-time student_____  Part-time student_____

I will participate as: (circle choice)

        Undergraduate                        Graduate                           Non-student

Trip Option Selection: (circle choice)

         Option I (Complete trip, 4cr.)               Option II (Galapagos only, 3cr.)
Roommate preference:_______________________________________________________________________________

A limited number of stipends are available, based on financial need.
_____ Check here if you would like to be considered for a stipend.


_____ Enclosed is my check in the amount of $200 payable to Penn State University.

_____ Charge my credit card.   (Visa _______   Master Card _______ )

Account number:____________________________________________________________ Expires:_______________

Cardholder's signature:____________________________________________________________________________


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Updated February 2, 1999