Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Race

Please choose as many as apply

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

 Prefer Not to Answer

 Other

Ethnicity

Hispanic/Latino

Not Hispanic/Latino

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Student Mobile

Instructors often find it helpful to have student mobile numbers to coordinate office hours and course logistics. This is completely optional and leave it up to the discretion of each parent.

(###)

###

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Cell Phone Communication

I am okay with instructors messaging or calling my child.

I am not okay with instructors messaging or calling my child.

Name

First Name

Last Name

Phone

(###)

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Opt out of receiving text messages

 I don't want to communicate via text message