You may also fax the completed form to us at 631 287 8253. The registration fee is waived if you do so.

The Application for Summer Housing is also available here. If you have questions, call 631 287 8175 or send e-mail to summer@southampton.liunet.edu.

Social Security Number:
Last Name:
First Name:
Middle Initial:
Address:


City:
State:
Zip:
Country:
Phone Number (area code first):
Sex:
Date of Birth:
Dorm (if applicable):
Major:

Student Status (please check one from each of A and B):

• A:
  • Undergraduate
  • Graduate

• B:
  • Continuing
  • Re-Admit
  • New Freshman or Grad
  • New Transfer
  • Visiting
  • Special

Please complete all information below, grouping courses by session number. Use the session legend provided below to determine the proper session number.

• Course 1:
• Course 2:
• Course 3:
• Course 4:
• Course 5:
• Course 6:

Official comments and approvals (Applicant: do not complete):

Visiting and Special Students please complete:

Is this your first time enrolled at any college? ___ No ___ Yes
If No, do you hold a baccalaureate degree? ___ No ___ Yes

If you are currently attending another college or university, please fill in the name and address of your home school:

School:
Address:

City/State/Zip:

Approval of registration from home school:

Advisor's Signature:

Student Signature:

My signature authorizes my registration for summer school. A bill and schedule will be issued and forwarded to me by mail. I understand that if I fail to cancel my registration prior to the first class session I will be held financially liable and subject to the refund schedule in effect for this program. Program changes, drops, adds or withdrawals must be done in writing to the Registrar's Office. I understand that my enrollment at Southampton Graduate Campus in no way implies matriculated status in a degree program.

SUMMER HOME

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