Sample Registration Form
Name of School
                                     Address of School
                                  Phone Number of School
Applicant Name
Social Security Number _______-_____-________
Address
City/State/Zip
Date of Birth (MM/DD/YYYY):
Hispanic: __Yes __ No                        Race (Check one):
                                             __ White/Caucasian
                                             __ Black/African American
                                             __ American Indian or Alaska Native
                                             __ Asian
                                             __ Hawaiian Native or other Pacific Islander
                                             __ Multi-racial
                                             __ Other
Disability: __ Yes __ No
Highest Grade Completed:
       __ Less than high school graduation
       __ High School Graduate     Graduation Date ___________
       __ GED      Date GED Attained _____________
       __ Some Post H.S., no degree or certificate __ Certificate (< 2 years)
       __ Associate Degree (Year:______)           __ Bachelor Degree or Above (Year:______)
       Name and Address of Last School Attended____________________________________
       ________________________________________________________________________
_____________________________________________________                  _________________
Applicant Signature                                                    Date Signed