5247/70714–ADVANTAGEPROGRAMENROLLMENTFORM.DOC|030714
ADVANTAGEPROGRAMENROLLMENTFORM
YearandsemesteryouwishtobegintheAdvantageprogram:20______FallSpring
Name:______________________________________________________PreferredName:___________
Last First Middle
MailingAddress:________________________________________________ _______________________
_____________________________________________________________________________________
CityStateZip
Phone:_______________________________Cell:_________________________________________
Gender:FemaleMaleBirthDate:____/____/____E‐mailAddress:_____________________
CountryofCitizenship:________________________CountryofBirth:__________________________
IfnotaU.S.citizen,checktypeofvisa:Stude nt PermanentResidentVisitorDependent
IsEnglishyourprimarylanguage?YesNoIfno,whatis?_______________________________
Name
ofparent(s)orguardian(s)withwhichyoureside(ifapplicable):___________________________
Nameandmailingaddressofnextofkin:___________________________________________________
Name
Nextofkinrelationtoyou:_______________________________________________________________
_____________________________________________________________________________________
CityStateZip
NameofHighSchool:___________________________Phone:________________________________
SchoolAddress:________________________________________________________________________
_____________________________________________________________________________________
CityStateZip
IaffirmthatORUhaspermissiontodiscussmyacademicprogress withrepresentativesofmyschooland
sendmyORUtranscript(s)tomyschool.
StudentSignature:__________________________ParentSignature:____________________________
SCHOOL’SAPPROVALTOENROLL:
CounselorName:___________________________PrincipalName:______________________________
CounselorSignature:________________________PrincipalSignature:___________________________