2021-2022 Student Registration Form

2021-2022 Student Registration Form

Fill out the form carefully for registration
Student Name *

First Name Middle Name Last Name
Birth Date *

Month Day Year
Gender
Student Phone Number *
Student E-mail (Use personal) *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent/Guardian 1 Name *

First Name Last Name
Parent Phone Number *
Parent E-mail *
example@example.com
Student ID *
Name of School *
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)
List at least 5 colleges/universities you are interested in attending. If Military, list branch
Please add any Additional Comments (Interested in playing sports in college, SAT/ACT scores, GPA, etc.)
Should be Empty: