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Name:________________________________________________________________________
Last First Middle Initial
Student ID Number: _______________ UMMC Email: _______________________
Gender: Female Male Polo shirt size: (men and women’s cut) _______ T-shirt size: ___
Present Address: ________________________________________________________________
Street Address City, State Zip
Permanent Address: _____________________________________________________________
Street Address City, State Zip
Local Phone Number: (____) ______________ Cell Phone Number: (____) _____________
Emergency Contact:
Name __________________ Relationship _______________ Phone Number ______________
School: ________________________
Number of semesters you have attended UMMC (including current semester): ______
How many semesters do you have left at UMMC: ______
Anticipated Graduation Date: Fall Spring Year: ______
What activities and student organizations have you been involved in at UMMC? Please list dates.
Specialty / Area of Study (if applicable): ________________________
