ENROLLMENT FORM 2013-2014

Name:      PID: A--

Local Phone #: ( ) -     Primary E-mail address:

Secondary E-mail address:

Local Address:

City, State, Zip:       Cell Phone #: ( )-

Permanent Address:

City, State, Zip:      Permanent Phone #: ()-

College:    Major:    Minor:

Class Level: Freshman Sophomore Junior Senior

Expected Graduation Date: Incoming GPA (only if you are a freshman): Transfer GPA:

Cumulative UC GPA: Major GPA:

If you transferred to UCSD, please list name of college/university & the city

How did you hear about CAMP? (if from a friend, faculty or staff member, please list his/her name)

Please indicate your graduate or professional school degree objective:

B.S.   M.S.   Ph.D.   M.D./Ph.D.   M.D. Teaching Credential   Other:

Proposed field of graduate study (if any): Beginning:

What is your career objective?

Have you ever participated in any of the following UCSD programs or any other similar program at the University of California?
Faculty Mentor Program Cal Soap Health & Medical Professions Preparation Program (HMP3)
McNair Program OASIS Transfer Admission Guarantee (TAG)
CSEMS or S-STEM Upward Bound Hughes Scholars Program (HSP)
NACME Upward Bound Math and Science Internship Experience and/or Summer Research @ in
UC LEADS Educational Talent Search Student Support Services Program (SSSP)
Amgen Summer Bridge - Year: Initiative for Maximizing Student Diversity (IMSD)
MARC EAOP Other:

 Gender: Female Male

Ethnicity: Birthdate:

Citizenship: U.S. Citizen Permanent Resident Other:

I authorize / do not authorize, the CAMP Coordinator/Office to publish, when appropriate , my name, class level, major, and photo on the CAMP Website or in CAMP/AEP publications as: CAMPís Leadership Prize recipient, CAMPís GSAA recipient, Provostís Honorsí Awardee, UCSD Graduate, starting, attending or having completed graduate school, Summer/Academic year Research Program and/or Internship participant, participating in a conference, recipient of other honors, awards or scholarships, etc. I understand that I will not be compensated for this use. Please note that not agreeing to this release will not affect your membership and status in CAMP.


Please review the above information to make sure that is a correct representation of yourself. Then digitally sign your name in the box below and submit your application.

Signature:    Date: