Cal STAPH Membership Form
Please complete the following information to register as a member of Cal STAPH. You must re-submit the membership form each year to maintain active membership.

If you have any questions, please contact the Cal STAPH Coordinator at staph@berkeley.edu.
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General Information
First Name *
Last Name *
UC Berkeley Email Address *
Please enter your UC Berkeley email address, even if this is not your primary email account.  This will be your Cal STAPH User ID.
Cell Phone Number
*
xxx-xxx-xxxx
Name of Emergency Contact, their phone number, and relationship to you *
Your emergency contact person must be someone who can legally make medical decisions on your behalf.
Expected Year of Graduation *
Please provide your best estimate.
What degree program are you enrolled in? *
Area of Concentration *
Background and Experience
Please note that no particular skill set or experience is required to become a member of Cal STAPH.
Computer skills
(Intermediate level and above)
Languages spoken other than English
(Intermediate level and above)
Interests
Which of the following Cal STAPH activities would be of interest to you? *
Choose all that apply.
Required
Which of the following activities best match your skills or interests? *
Choose all that apply.
Required
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