UTOP Participant Application

This application should be returned to:
Academic Initiatives For Mentoring Students
University of North Carolina at Charlotte
318D Fretwell Building
Charlotte, NC 28223-0001

Please note: You must be formally accepted by UNC-Charlotte to attend UTOP.  You can apply now and your name and information will be placed on the list for the program however if you are not granted admission by June, 2005, your application becomes null and void.
Upon acceptance to UNC-Charlotte and the UTOP program there will be a $200 non-refundable activity fee for each applicant to hold your place for UTOP summer 2005. Please mail your check or money order to: Dr. Gregory Davis, UTOP Program, 9201 University City Blvd., Charlotte, NC 28223. Please make checks payable to UNC-Charlotte/UTOP.

Full Name

SID#

 (voluntary)

Local Address

City

       State     Zip

Phone

       E-mail

Permanent Address
City

  State     Zip

Intended Major

 

                Participant Agreement

By signing this form I consent for UNC Charlotte to release all university records relating to my enrollment, attendance, courses, course grades, and other academic assessment to UTOP staff members. Staff members will use this information in determining what classes will be most beneficial to UTOP students.

Print Name      

Signature          ____________________________                Date                

 

Before Sending This Form

STEP 1:  Review this form for accuracy and make sure all fields are complete.
STEP 2:  Press the SEND button to submit the form.
STEP 3:  Press YES/OK on the submission pop-up window.
   (If your browser is not configured to send email  you will receive an error.)
STEP 4:  Press the DONE button.

UTOP Counselor Application. Copyright © 1999 [Academic Initiatives For Mentoring Students]. All rights reserved. Revised: October 20, 2004

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