Student Application
College Application Education Project
Arthur Akers
Student Information
Name
First Name
Last Name
Birth Date
-
Month
-
Day
Year
Date Picker Icon
Gender
Please Select
Male
Female
Ethnicity
Please Select
African American
Hispanic/Latino
Asian
Caucasian
Native American/Alaskan
Hawaiian/Pacific Islander
Middle Eastern
Prefer not to answer
Other
Email Address
School
Grade
Current Residence Information
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
-
Area Code
Phone Number
Cell Phone Number
-
Area Code
Phone Number
Emergency Phone #1
-
Area Code
Phone Number
Emergency Phone #2
-
Area Code
Phone Number
Please list any of the following: Current medications, Medication allergies, Food allergies, Chronic health concerns.
Notes
Please inform the office of any other vital information you think they may need to know in the event of an emergency. Thank you.
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