Student Registration Form

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ABOUT
- OUR TEAM
- CAREER OPPORTUNITIES
INDIVIDUAL STUDENT SERVICES
INSTITUTIONAL SERVICES
RESOURCES
REVIEWS

CONTACT

Student Registration Form

Stud Info

STUDENT INFORMATION

Student's Name:

Date of Birth

Gender

Home Address

Student Resides with: (Check all that apply)

Mother

Father

Stepmother

Stepfather

Guardian

Other

Student's Cell Phone Number

Student's Email Address

ADD STUD INFO

ADDITIONAL STUDENT INFORMATION

HELP US GET TO KNOW YOUR STUDENT BETTER

Please list your student's favorite activities

Please list your student’s school and community involvement:

Please use 3-5 words to describe your student:

Please share with us any other additional information that will help us better understand your student:

EDUCATION INFORMATION

EDUCATION INFORMATION

Current School:

Grade

7th

8th

9th

10th

11th

12th

Expected Year of Graduation

GPA

Student’s Curriculum includes: (Check all that apply)

College Prep

Honors

AP

IB

Community College Course

Has your student been diagnosed with a learning disability? If yes, please list the diagnosis(es):

Does your student have a 504 Plan or IEP? My student has a:

504 Plan

IEP

STANDARDIZED TESTING INFORMATION

STANDARDIZED TESTING INFORMATION

PSAT Total Score:

Test Date:

SAT Total Score:

Test Date

SAT Total Score

Test Date:

ACT Composite Score:

Test Date

ACT Composite Score:

Test Date

PARENT/GUARDIAN INFORMATION

PARENT/GUARDIAN INFORMATION

Parent /Guardian Name:

Home Address

Cell Phone Number:

Email Address

Education (Highest degree completed):

High School Diploma or GED

Bachelor’s Degree

Doctorate

Some college

Master’s Degree

Associates Degree

Professional Degree

College/University Attended:

Degree Received

College/University Attended:

Degree Received:

Current Employer:

Position

Marital Status:

Married

Divorced

PARENT/GUARDIAN INFORMATION

PARENT/GUARDIAN INFORMATION

Parent/Guardian Name:

Home Address

Cell Phone Number

Email Address:

Education (Highest degree completed):

High School Diploma or GED

Bachelor’s Degree

Doctorate

Some college

Master's Degree

New Option

Professional Degree

College/University Attended

Degree Received

College/University Attended

Degree Received

Current Employer

Position

Marital Status

Married

Divorced

ADDITIONAL PARENT/GUARDIAN INFORMATION

ADDITIONAL PARENT/GUARDIAN INFORMATION

Parent/Guardian Name:

Home Address

Cell Phone Number

Email Address:

Education (Highest degree completed

High School Diploma or GED

Bachelor’s Degree

Doctorate

Some college

Master's Degree

Associates Degree

Professional Degree

College/University Attended

Degree Received

College/University Attended

Degree Received

Current Employer

Position

Marital Status:

Married

Divorced

ADDITIONAL PARENT & FAMILY INFORMATION

ADDITIONAL PARENT & FAMILY INFORMATION

HELP US GET TO KNOW YOUR FAMILY BETTER

Please list parent/guardian community involvement

Please list siblings in family:

Name: