University Enrollment Form

Full Name

First NameLast Name

Date of Birth

Date

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Home Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Department

If Other, please specify your department

Guardian Contact Full Name

First NameLast Name

Relationship to Student

Guardian Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Guardian Contact Email

example@example.com

Do you have any medical conditions or allergies?

If yes, please list your medical conditions or allergies

Current Medications

Upload Immunization Records

Preferred Housing Type

Do you have a preferred roommate?

If yes, please provide your preferred roommate's name

Do you have any accessibility needs?

Are you interested in scholarships?

Which scholarship opportunities interest you?

Upload Your ID, Transcript, and Proof of Residency.

Student Signature

Financial Aid and Scholarship Interest