Summer Term 2010

Student ID:
(please provide if applicable)
Select a Campus

Main Campus or Penn Manor Course
Schuylkill Center
Philadelphia Center

Select a Department

Undergraduate and Continuing Studies
Graduate


PERSONAL DATA
Prefix:
First Name:
*
Last Name:
*
Middle:
Suffix:
Date of Birth:
*
Social Security Number:
e.g. (xxx-xx-xxx)*
Address:
*
City:
*
State:
*
Zip:
*
Country:
*
Email Address:
*
Home Phone:
e.g. (xxx) xxx-xxxx*
Work Phone:
e.g. (xxx) xxx-xxxx
Are you
participating
in Act 48?

Yes *
No


COURSE SELECTION
Course 1:
*
Course 2:
Course 3:
Course 4:
Course 5:

OPTIONAL INFORMATION
Gender:

Male
Female

Ethnic Origin:

American Indian or Alaskan Native
Asian
Black/African American
Hispanic
Native Hawaiian or Other Pacific Islander
White/Caucasian
Two or More Races
Other (please specify)

Marital Status:
Religion:

Islam
Jewish
Protestant
Baptist
Luthern
Presbyterian
UCC
United Methodist
Other Protestant
Roman Catholic
Other (please specify)


SIGNATURE
To the best of my knowledge, the above information is true.
I agree that, if accepted, I will comply with the rules and regulations of Alvernia University.

Signature:
*
*
I acknowledge and accept the tuition fees, as published in the applicable catalogue that will be incurred by this registration request.

Alvernia University complies with all federal, state, and local nondiscrimination laws in the administration of its educational programs and services and in its employment relationships.

* required field