Student Registration Form

Student Registration Form

Fill out the form carefully for registration
Student Name *

First Name Middle Name Last Name
Birth Date *

Month Day Year
Gender
Parent/Guardian 1 Name *

First Name Last Name
Parent/Guardian 2 Name (if no 2nd parent, please leave blank)

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Student E-mail (Use personal, not school) *
example@example.com
Student Phone Number *
Parent 1 Phone Number *
Parent Email *
example@example.com
Parent 2 Phone Number
School Name *
Student ID *
Graduation Year *
Please choose your Post High School Interests (you can choose more than one)

HBCU (Historically Black Colleges & Universities) CSU/UC Community College Trade Military Other (Out of State)
Please add any Additional Comments (Interested in playing sports in college, SAT/ACT scores, GPA, etc.)
Should be Empty: