P.O. Box 4662, Antioch CA 94509
Login
Home
About
Who We Are
Our Partners
Contact
Programs
College Tours
Events
Calendar
Upcoming Events
Donate
CHECK ONE:
HBCU
California
Last Name:
First Name:
Midle Initials
Home Address
Apt. #
City
State
Zip Code
Sex - M/F
Cell Phone
Email Address
High School Attending
Grade
DOB
MM slash DD slash YYYY
Emergency Contact Person
Phone Number
Relationship to Student
Are you currently involved in school activities?
Yes
No
Please specify
Have you ever visited college/university campuses outside of California?
Yes
No
Please specify
Do you have any brothers/sisters currently enrolled in college?
Yes
No
Please specify
Has either of your parents attended college?
Yes
No
Please specify
Personal Health History (to be completed by parent or guardian)
List any medications to be taken while on the tour:
General Information:
Asthma:
Yes
No
Diabetes:
Yes
No
High Blood Pressure:
Yes
No
Allergies:
Yes
No
Heart Trouble:
Yes
No
Convulsions/Seizures:
Yes
No
List any physical or behavioral conditions that may affect or limit full participation in strenuous walking tours:
Name of Primary Care Physician
Phone Number
Personal Health Insurance carrier
Policy Number
Date
MM slash DD slash YYYY
* I hereby declare that all the above information furnished is true to the best of my knowledge and belief
*
*
I hereby declare that all the above information furnished is true to the best of my knowledge and belief