College Student Registration Form
Name
*
First Name
Last Name
Campus Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Student Email address
*
example@example.com
Personal Email address
*
example@example.com
Informal Name
Date of Birth
*
-
Month
-
Day
Year
Date
Cell Phone Number
*
-
Area Code
Phone Number
What school do you attend?
*
NIU
Kish
What is your Major?
What year do you expect to graduate?
*
Emergency Contact Person
*
First Name
Last Name
Emergency Contact Phone Number
*
-
Area Code
Phone Number
Submit
Should be Empty: