1st choice : mm/dd/yy

2nd choice : mm/dd/yy

3rd choice : mm/dd/yy

Enter today's date: mm/dd/yy

Student's name:

Parent's name:

Home phone number:

Primary contact e-mail address:

Enter primary e-mail address again:

Enter home street address, city, state, zip in the space provided below

  (eg. 3856 E. Oak St., Phoenix, AZ 85008)

Student's current school:

Student's current grade:

Name of preferred freshman to shadow or enter N/A if you have no preference:

Enter student's special interests:

Comments:

 ------------ OFFICE USE ONLY BELOW THIS LINE -------------

Assigned Student Diplomat