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First Name*:		Middle Name:		Last Name*:
Address*:
City/Town*:		State/Province*:		Zip/Postal Code*:
Country*:			Email*:
Phone Number*:	(e.g. xxx-xxx-xxxx)		Fax Number:	(e.g. xxx-xxx-xxxx)

What year did you graduate from High School?*:
High School Name & State/Province:	College or University Name & State/Province (if transferring):
1. 2. 3.	1. 2. 3.

Anticipated Entering Semester:	Spring 2010 Fall 2010 Spring 2011 Fall 2011 Spring 2012 Fall 2012 Spring 2013 Fall 2013
Academic Interest:	Behavioral Science Biology Business Management Business (2 yrs) Computer Applications Computer Science (2 yrs) Criminal Justice (2 yrs) Electronic Commerce Elementary Education English Environmental Studies Forest Technology (2 yrs) French General Studies (2 yrs) Human Services (2 yrs) Nursing Public Safety Administration RN-BSN Secondary Education-Bilingual Education Secondary Education-English/Drama/Language Arts Secondary Education-Mathematics Social Science Field Teacher Certification-Elementary Teacher Certification-Secondary University Studies Not Sure
If you chose Teacher Certification-Secondary above please choose from the following options: -- Foreign Language English Math Science Social Science Business
Clubs, Activities, & Interests:
Varsity Sports Interest:	-- Alpine Skiing Basketball Cross Country Men's Golf Nordic Skiing Soccer Women's Volleyball -- Alpine Skiing Basketball Cross Country Men's Golf Nordic Skiing Soccer Women's Volleyball
Please contact me regarding a campus visit:	No Yes
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