CREST Program
Course Enrollment AND Self Payers Form
QUARTER: Summer 2015
UCSD residents, fellows (including laboratory-based fellows), faculty, and staff pay a discounted fee.
The fee covers the costs for lectures materials including books.
PAYMENT DEADLINE: May 22, 2015
Name:
r MS. r MR. r DR. r MISS r MRS.
Email:
Position/Title:
Dept.: UCSD Mail Code:
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 Card: #______
Exp Date: ______/ ______Signature:
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COURSE TITLE SECTION ID SECT ID for BB DISCOUNTED FEES CLASS DATE /CLASS TIME
(For Office use) (circle one for each course) Mon -Thu (circle time preference)
1) Biostats I (CLRE- 253), 2 units 108928 108931 UCSD Fellow/Staff: $536 Wednesdays 2 –3:50pm 4 - 5:50 pm
Biostatistics I 108929 UCSD Faculty: $750 Wednesdays 2 –3:50pm 4 - 5:50 pm
2) Epi I (CLRE-251), 2 units 107329 108889 UCSD Fellow/Staff: $536 Thursdays 2 –3:50pm 4 - 5:50 pm
Epidemiology I 108884 UCSD Faculty: $750 Thursdays 2 –3:50pm 4 - 5:50 pm
3) HSR (CLRE-252), 2 units 108891 108896 UCSD Fellow/Staff: $536 Thursdays 4 - 5:50 pm
Health Services Research 108894 UCSD Faculty: $750 Thursdays 4 - 5:50 pm
4) POR I (CLRE-250), 2 units 108932 108935 UCSD Fellow/Staff: $536 Wednesdays 4 - 6:00 pm
Patient Oriented Research I 108933 UCSD Faculty: $750 Wednesdays 4 - 6:00 pm
5) Sci. Com. Sem. (CLRE-259),2 units 108936 108939 UCSD Fellow/Staff: $536 Tuesdays 4 - 6:00 pm
Scientific Communication Skills Sem. 108937 UCSD Faculty: $750 Tuesdays 4 - 6:00 pm
6) PD -Group Coaching (CLRE-258), 108940 108996 UCSD Fellow/Staff: $536 Mondays 1 - 3:50 pm
2 units, Personal Development Sem. 108941 UCSD Faculty: $750 Mondays 1 - 3:50 pm
Total: $
Please RSVP to Seble by May 1st, 2015 if you would like to enroll in Sci. Com. And /or Personal Development Seminar
Submit completed form with check or completed credit card information to:
UCSD Extension Student ServicesNola Green
UNEX Campus center
9600 N. Torrey Pines Rd, Building ‘C’
La Jolla, CA, 92093-0176H
Inter-campus Mail code: 0176H / Phone: 858-534-3420
Fax: 858-534-8527
web: http://extension.ucsd.edu/