2017 APPLICATION FORM FOR 100 SCHOLARS U G Berkeley Summer Sessions ...

2017 APPLICATION FORM FOR 100 SCHOLARS

U

Berkeley Summer Sessions | 1995 University Ave., Suite 130, Berkeley, CA 94704 | Fax: 510.664.9825 | E-mail: summer@berkeley.edu

PERSONAL INFORMATION

G

* Required Field

Last Name* (Family Name/Surname)

as appears in passport

First Name* (Given Name)

Middle Name

as appears in passport

as appears in passport

Sex* (Gender):

Birthdate* (MM-DD-YYYY)

Male

Female

Decline to state

Street Address*

City*

State/Province

Zip/Postal Code*

E-mail Address*

COURSE SELECTION

Subject*

Telephone Number*

PAYMENT INFORMATION

Fax/Alternate Number

STUDENT INFORMATION

* Required Field

Catalog

Number*

Class

Number*

100

12345

Session*

C

Grading

Option*

Units*

2

$920

* Required Field

What is your current Visa Status?*

Permanent Resident

Other

Are you currently an enrolled college student?

COURSE 4 COURSE 3 COURSE 2 COURSE 1

Ex.

Country*

No

Yes

Name of the school you currently attend

Have you received the equivalent of a U.S. Baccalaureate (BA/BS)

Degree?*

Yes

No

Have you applied for admission to UC Berkeley for Fall 2017?

Yes

No

Have you attended UC Berkeley before?*

Yes

No

Name of the school you currently teach at

Name of the school district

* Required Field

Maximum $3,840 + Registration Fee $ 380.00 + Document Management Fee $55.00 = YOUR TOTAL FEES DUE* $ 435.00

The Total of All Tuition from above* $ _____________

I understand that Berkeley Summer Sessions is allowing me to register using this paper application due to circumstances that have prevented me from using

the online application form. I agree to establish my CalNet ID and pay my fees in full via Calcentral ().I understand that my

transcript will be blocked, late fees will be assessed and the University may refer my account to a commercial collections agency should I fail to pay my fees.

Signature*

STUDENT SIGNATURE

Date*

* Required Field

I understand that the admission to Berkeley Summer Sessions is conditional on compliance with University policies, and may be revoked at the discretion of Summer Sessions

in accordance with the Code of Student Conduct (sa.berkeley.edu/code-of-conduct). I also agree to the rules regarding fees, refunds, and enrollment changes published on

the Summer Sessions website (summer.berkeley.edu), including, but not limited to, the $100 NON-REFUNDABLE portion of the fees.

Signature*

Date*

EMERGENCY CONTACT INFORMATION

Berkeley Summer Sessions | 1995 University Ave., Suite 130, Berkeley, CA 94704 | Fax: 510.664.9825 | E-mail: summer@berkeley.edu

PERSONAL INFORMATION

* Required Field

Student Name*

Student E-mail*

EMERGENCY CONTACT 1

Student Phone Number*

* Required Field

First Name*

Last Name*

Relationship*

E-mail*

Phone Number*

Alternate Phone Number

EMERGENCY CONTACT 2

* Required Field

First Name*

Last Name*

Relationship*

E-mail*

Phone Number*

Alternate Phone Number

EMERGENCY CONTACT INFORMATION RELEASE AUTHORIZATION

Under the Federal Family Education Rights and Privacy Act of 1974 and provisions of state law relating to public records disclosure, the University of California Policies Applying

to the Disclosure of Information from Student Records and the Berkeley Campus' implementation of that policy assure that student information is protected.

In case of an emergency, it may be necessary to access and release your information protected by the

aforementioned law and policies. By checking this box, you are giving your written consent to access and

release relevant information to appropriate parties connected with the emergency.

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