Date:
Name:
SS#
Date of Birth
Complete home mailing address with street, city, state and zip code
How will you be attending Full Time
Part Time
Flexible
Home Phone
Work or Mobile Phone
Email Address:
In case of emergency, please contact (name & number)
Your Age
Parents name if under 21
Height
Weight
Race
Sex Male
Female
Marital Status Single
Married
Separated
Divorced
Widowed
General Health Excellent
Good
Fair
Poor
If health is other than excellent please explain
High School Attended
Highest grade completed 9
10
11
12

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