CREST Program

Course Enrollment AND Self Payers Form

QUARTER: FALL 2017

UCSD residents, fellows (including laboratory-based fellows), faculty, and staff pay a discounted fee.

Fees cover the cost of lectures, materials and textbooks.

PAYMENT DEADLINE: August 25th , 2017

Name:

r MS. r MR. r DR. r MISS r MRS.

Email Address:

Address:

Students PID: (please contact Seble: 858-534-9163/ if you don’t know your PID)

Work Phone: ( ) Home/Cell Phone: ( )

DISCOUNT FEE CATEGORY (check one):
UCSD STAFF ______UCSD FELLOW ______UCSD FACULTY

PAYMENT METHOD (check one):

______Personal Check (Made payable to UC Regents)

______Visa, MasterCard, Discover, American Express, and Diners Club Card: #______

Exp Date: ______/ ______Signature:

COURSE TITLE SECTION ID DISCOUNTED FEES CLASS DATE CLASS TIME

(For Office use) (circle one for each course) Tues -Thur (circle time preference)

1) Biostats II (CLRE- 254), 2 units 125986 UCSD Fellow/Staff: $570 Wed 2pm–3:50pm OR Thurs 4–5:50pm

Biostatistics II 125987 UCSD Faculty: $790 Wed 2pm–3:50pm OR Thurs 4–5:50pm

2) Data Mgmt. (CLRE-255), 2 units 125989 UCSD Fellow/Staff: $570 Thursdays 4 - 6 pm

Data Management/Informatics 125990 UCSD Faculty: $790 Thursdays 4 - 6 pm

3) Epi II (CLRE-257), 2 units 125992 UCSD Fellow/Staff: $570 Thursdays 4 - 6 pm

Epidemiology II 125993 UCSD Faculty: $790 Thursdays 4 - 6 pm

4) POR II (CLRE-256), 2 units 125983 UCSD Fellow/Staff: $570 Wednesdays 4 - 6 pm

Patient Oriented Res. II 125984 UCSD Faculties: $790 Wednesdays 4 - 6 pm

5) Prof. Dev. Seminar (CLRE-258), 2 units 125998 UCSD Fellow/Staff: $570 Tuesdays 3:30 - 6:30 pm

Research Budgeting, Fiscal Mgmt. Billing 125999 UCSD Faculty: $790 Tuesdays 3:30 - 6:30 pm

Total: $

Please RSVP to Seble by August 16, 2017 if you would like to enroll in CLRE 258 - Research Budgeting and Billing

Submit completed form with check or completed credit card information to:

UCSD Extension Student Services
UNEX Campus center
9600 N. Torrey Pines Rd, Building ‘C’
La Jolla, CA, 92093-0176H
Inter-campus Mail code: 0176H / P: 858-534-3400
F: 858-534-8527
web: http://extension.ucsd.edu/