Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Race/ethnicity *

Please choose as many as apply.

African American

Arab

Black

Caribbean

Caucasian

East Asian

First Nations

Latinx

Middle Eastern

Native American

Pacific Islander

South Asian

Southeast Asian

White

Prefer Not to Answer

Other

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.

(###)

###

####

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 1

First Name

Last Name

Phone 1

(###)

###

####

Opt out of receiving text messages

I don't want to communicate via text message