Student Information Collection Form

Student Information Collection Form
General Information
Name *

First NameLast Name
Email*
example@example.com
Phone*
Please enter a valid phone number.
Birth Date *

MonthDayYear
Date
Ethnicity*
Gender*

Prefer Not AnswerMaleFemaleOther
Course Interest*
Highest Level of Education *
GED or Higher required
Are you a U.S. Military Veteran?

YesNo
Which semester are you looking to start? *

Fall 2025Winter 2025Spring 2025Summer 2025Unsure
Interested in Day or Eve?

DayEvening
This is a fill-in-the-field. Please add appropriate blank fields and text.
Your County of Residence?
Should be Empty:

General Information