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     ____________