***Registration Form***
Registration Form
First Name:
Last Name:
Social Security Number:
Address #1:
Address #2:
City:
State:
Zip:
Email address (optional):
Date of Birth:
Month:
January
February
March
April
May
June
July
August
September
October
November
December
Date:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year:
Gender:
Male
Female
Marital Status:
Single
Married
Divorced
Name of High School:
Year Graduated:
Name of college in which you are attending:
ECCC
EMCC
MCC
MSU Meridian
What is your major?
What is your grade level?
Freshman
Sophmore
How many semester have you attended this college?
1
2
3
4
5 or more
Are you a part-time or a full-time student?
Part-time(1-11hrs)
Full-time(12hrs or more)
Comments?: