Summer Institutes for Educators Course Enrollment Form

University of the Pacific, Benerd College

Legal first and last name: *

Middle Initial:

Preferred First Name:

Street address: *

City *

State *

Zip code *

Personal/Home Email Address: *

Phone number (numbers only) *

Date of birth * +

Have you previously attended Pacific? *

Year attended

Name while you attended

Student ID number:

Subject taught *

Grade level: *

School: *

School district: *

How did you find out about this class?: *

Please choose the course you would like to register for from the drop down menu: *

Please select your preferred grading option *