Registration Form

JOIN US:
on Our Spring 2022 College Tour
(1-Day Tour)

to NC A&T University
and NC Central University

April 19th, 9 am – 5 pm

Cost: $20

Student Information

Student's Last Name

Student's First Name

Student's Middle Initial

Student's Home Address

City

State

Zip Code

Student's Cell Phone Number

Student's Email

Student's Date of Birth

Student's Gender

Gender

Student's T-Shirt Size

T-shirt Size

High School Information

High School Attending

Grade

High School Activities

College Information

Schools of Interest

Desired Major

Extracurriculars of Interest

Parents/Guardian Information

(Parent's/Guardian's) Last Name

(Parent's/Guardian's) First Name

(Parent's/Guardian's) Home Address

What do your parents do for a living?

(Parent's/Guardian's) Cell Phone Number

(Parent's/Guardian's) Email

Emergency Contact Information: In the case that above Parent/Guardian can not be reached.

Emergency Contact's Last Name

Emergency Contact's First Name

Relationship to Student

Emergency Contact's Home Address

Emergency Contact's Primary Phone Number

Emergency Contact's Primary Email

Health / Medical Information

Do you have any medical history of the following conditions:

Would you be taking any medications on the tour? If so, please list them?

Do you have any allergies?

Are there any medications that you will need to have on the tour with you? If so, please list them.

Primary Care Physician

Primary Care Physician Phone Number

Primary Health Insurance

Policy Number

Do you have any special dietary requirements?

Do you require any special accommodations? If yes, please state them.

Would you like to purchase travel insurance?

Yes No

Additional Information

Please share any additional information that you think is important for us to know.

What are your expectations from this trip?

I hereby declare that all the above information furnished is true to the best of my knowledge and belief.

Yes No

Student Information

Student's Last Name

Student's First Name

Student's Middle Initial

Student's Home Address

City

State

Zip Code

Student's Cell Phone Number

Student's Email

Student's Date of Birth

Student's Gender

Gender

Student's T-Shirt Size

T-shirt Size

High School Information

High School Attending

Grade

High School Activities

College Information

Schools of Interest

Desired Major

Extracurriculars of Interest

Parents/Guardian Information

(Parent's/Guardian's) Last Name

(Parent's/Guardian's) First Name

(Parent's/Guardian's) Home Address

What do your parents do for a living?

(Parent's/Guardian's) Cell Phone Number

(Parent's/Guardian's) Email

Emergency Contact Information: In the case that above Parent/Guardian can not be reached.

Emergency Contact's Last Name

Emergency Contact's First Name

Relationship to Student

Emergency Contact's Home Address

Emergency Contact's Primary Phone Number

Emergency Contact's Primary Email

Health / Medical Information

Do you have any medical history of the following conditions:

Would you be taking any medications on the tour? If so, please list them?

Do you have any allergies?

Are there any medications that you will need to have on the tour with you? If so, please list them.

Primary Care Physician

Primary Care Physician Phone Number

Primary Health Insurance

Policy Number

Do you have any special dietary requirements?

Do you require any special accommodations? If yes, please state them.

Would you like to purchase travel insurance?

Yes No

Additional Information

Please share any additional information that you think is important for us to know.

What are your expectations from this trip?

I hereby declare that all the above information furnished is true to the best of my knowledge and belief.

Yes No

Registration Form

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