Registration

School or Program Authorization Code:

About You and Your Household

Please fill in the following items to the best of your ability. Note: items with a * are required.

First Name *

Middle Initial

Last Name *

Street Address

City

State

Zip Code

Phone Number

Your Date of Birth *

Your Gender *

Your Email Address

Confirm Your Email Address

Confirm Email does not match

What is your academic classification? *

What is your enrollment status?

What is your major/program of study?

What is the primary language spoken in your home? (select one)

English

Spanish

Chinese

Japanese

Other

What best describes your racial and ethnic identity? (select all that apply)?

Asian/Pacific Islander

Black/African American

American Indian/Native American/Native Alaskan

White/Caucasian/Non-Hispanic

Latino/Hispanic

Mixed Racial or Ethnic Heritage

Prefer Not to Answer

What is the highest level of education completed by your parent(s)/guardians(s)?

Where do you live?

With whom do you live?

With Mother and Father

With Mother and Stepfather

With Mother Only

With Father Only

With Another Relative

On Your Own

Please choose a security question and answer so you can retrieve your answers at a later time.

Security Question

Security Question Answer