EmailMeForm
A-State Connection Application - 2019
When completing this form, please use correct capitalization and punctuation.
First Name of student
*
Middle Initial
*
Last Name of student
*
Gender
*
I am currently a student at
*
Complete High School Name
I am a
*
Senior
Junior
Mailing Address
*
Street Address
City
State / Province / Region
Postal / Zip Code
Student Home Phone Number
Include Area Code - numbers only
*
Student Cell Phone Number
Include Area Code - numbers only
*
Email Address
*
Date of Birth
mm / dd/ yyyy
*
MM
/
DD
/
YYYY
Ethnicity
*
African American
Asian American
Bi-/Multi-racial
Hispanic
Native American
Other
Parent / Guardian First Name
*
Parent / Guardian Last Name
*
Parent/Guardian Email
*
Parent / Guardian CELL or HOME Phone Number
Include Area Code - numbers only
*
Parent / Guardian WORK Phone Number
Include Area Code - numbers only
*
Are you registered with your high school disability services office?
*
Yes
No
List Extracurricular Activities / Community Service
*
250 characters or less
List Academic Honors and Special Awards
*
250 characters or less
What are your career plans and goals?
*
250 characters or less
Allergies:
Please list any allergies
If selected, will you need transportation to A-State Connection?
*
Yes
No
What is your t-shirt size
*
Small
Medium
Large
XL
2XL
3XL
Other
High School Counselor Name
*
Name of High School Counselor
High School Counselor Email Address
*
Cumulative Grade Point Average
*
Highest composite ACT score
*
Please provide a short answer response as to how participating in A-State Connection will assist with your future plans.
*
250 words or less
By submitting, I hereby agree that all information supplied in this application is complete and accurate.
*
Please select
Yes, I agree
By registering for this event, you agree to grant Arkansas State University the right to take photographs in connections with the above identified event.
*
Agree
Disagree