* - Denotes REQUIRED Information. Please be sure that you include an email address that you check frequently and use your current home and cell phone numbers.

*Name:   

*Gender: Female Male    *Age At Time Of Arrival:    

*Email Address :

Permanent Address:    City:    State:   Zip:

Local Address:    City:    State:   Zip:

*Home Phone #:    *Cell Phone #:

*High School:     *Graduating GPA:    *ACT Score:

*Anticipated Major:    Anticipated Minor:

*What issues do you anticipate needing assistance with?

Please list any high school organizations or extracurricular activities in which you participated.

What are your Hobbies/Interests?

Date of Freshman Orientation (mmddyyyy):

*I prefer a student mentor of my gender: Yes     No     No Preference