Register for our next orientation session:

1) Please check our web site to find out the dates in January 2004 for the next orientation sessions in your institution
(PLEASE NOTE: Only students enrolled in one of the four participant universities can register for this exchange program).

2) Then, fax this form (see number below) at least one week before the session. You'll receive a confirmation of registration from one of the program's coordinators.

Final selection of participant will take place after the January 2004 orientation session. Selected students will be contacted by program's coordinators.

For additional information, please contact us via telephone (++ 215-204-2712) or e-mail (online@temple.edu)

PLEASE USE PRINT LETTERS

First name: _____________________________

Middle name: ___________________________

Last name: ______________________________

Gender:  Female _____   Male ______

Institution in which you are currently enrolled (CHECK ONLY ONE):

                Temple University _____                        Universidade Federal da Bahia _____
                Bridgewater State College _____            Universidade Tuiuti do Parana _____

Student status (CHECK ONLY ONE):

                Freshman _____     Sophomore _____     Junior _____     Senior _____      Other _____

Academic program or department in which you are currently enrolled: ___________________________________

Your e-mail address: _________________________________________

Your daytime telephone number: _______________________________

Your mailing address: _______________________________________________________________________________

City: _____________________________

State: ____________________________

 

Please fax this form to:
OnLine Learning Program, Temple University
++ (215) 204-2666.