Last Name:    First Name:    MI:

Gender: Female Male    DOB (mmddyyyy):    Graduating GPA:

High School:     Email Address :

Mailing Address:    City:    State:   Zip:

Home Phone #:    Cell Phone #:

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