Touro University Nevada Registration Form
2026
Student Name
First Name
Last Name
Student DOB
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Ethnicity
Please Select
Native American
Hispanic
African American
Caucasian
Asian/Pacific Islander
Other
Preferred Language
Please Select
English
Spanish
Other
Do you agree to receive text message communications regarding this program?
Please Select
Yes
How did you hear about Diapers For Diplomas?
Have you participated in this program before?
Yes
No
Are you currently receiving services through The Jeremiah Program?
Yes
No
Are you currently experiencing financial difficulties related to diaper costs?
Yes
No
Do you require any disability-related accommodations?
No
Yes
If yes, please explain
Please select your Medicaid provider.
Please Select
Anthem
United Healthcare Health Plan of Nevada
Silversummit Healthplan
Molina Healthcare
CareSource
Emergency Medicaid
I don't receive Medicaid
Touro University Nevada Information
College/University Currently Enrolled
Please Select
TUN
NSU
UNLV
CSN
UNR
TMCC
DRI
GBC Pahrump
Full Time or Part Time
Full Time
Part Time
Estimated Graduation Date
-
Month
-
Day
Year
Date
Major/Field of Study
Submit Proof of Enrollment for 2026
Browse Files
(class schedule that includes your name)
Cancel
of
Child Information
Child's Name
Child's DOB
-
Month
-
Day
Year
Date
Apply Now
Should be Empty: