Student Referral Form

Your First Name:     Your Last Name:

E-mail:

Student's Information:

Student's First Name :       Middle:

Student's Last Name :

Address:

City:       State:       Zip:

Phone:

E-mail:

H.S. graduation year:

Ethnic Origin (optional):
1 White - non-Hispanic                 4 Asian/Pacific Islander
2 Black/African American             5 Hispanic/Latino  
3 Alaskan/American Indian           6 Nonresident alien (foreign)  
Tribal/nation affiliation:             

Gender:      M      F

Major or career interests:

Anticipated term of enrollment: Fall        Year 
                                                    Spring     Year
                                                    Summer   Year

High School:

City:       State:

What is your relation to this student?: