Southampton College: Summer Programs

SUMMER PROGRAMS

2005 Electronic Application for Summer Housing

An electronic Summer Course Registration form is also available here. If you have questions about this form, call 631 287 8175 or send e-mail to summer@southampton.liunet.edu.

You will have to enter your social security number below. If you are concerned about the security of electronic transmission, you may phone it in instead (631 287 8175).

Social Security Number:

Last Name:

First Name:

Middle Initial:

Street address:

City:

State:

Zip:

Country:

Home Phone (with area code):

E-mail:

Sex:
Female Male
Date of Birth:

Marital Status:
Single Married

Name of Parent or Guardian (if under 18 years of age):

Class: Freshman Soph. Junior Grad. Transfer Other

Are you a matriculated student of Long Island University? Yes No

If so, what campus are you matriculated with (as of 05/04)?

If Southampton, Campus Box Number:

Course(s) registered for:

Dept Course # Course Title Dates: From/To

Room Preference:
Double
Small Single
(NOT GUARANTEED -- assigned on a first come, first served space availability basis)
Mandatory Meal Plan* (choose one):
(*not required of institute participants)
15 meals per week
12 meals per week
8 meals per week

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