Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Race

American Indian or Alaskan Native

Black or African American

Asian

Native Hawaiian or Other Pacific Islander

White

Prefer not to answer

Other

Ethnicity

Hispanic/Latino

Not Hispanic/Latino

Prefer not to answer

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 left up to the discretion of each parent.

(###)

###

####

Cell Phone Communication

I am ok with instructors messaging or calling my child

I am not ok with instructors messaging or calling my child

Name

First Name

Last Name

Parent Phone

(###)

###

####

Opt out of receiving text messages

I do not want to communicate via text message