flamingoes REGISTRATION

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

Name
Last :________________________________  First:___________________________  Middle Initial:_________

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

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

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


ACADEMIC INFORMATION

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.



Deposit:

_____ 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