First Name: *

Middle Name:

Last Name: *

Maiden Name:

Date of Birth (MM\DD\YYYY): *

Gender: -Select One- Male Female *

Mailing Address: *

Apt Num:

City: *

State: -Select One- Armed Forces Americas excl Canada Armed Forces EurAlaska Alabama Armed Forces Pacific Arkansas American Samoa Arizona California Colorado Connecticut District of Columbia Delaware Florida Federated States of Micronesia Georgia Guam Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Marshall Islands Michigan Minnesota Missouri Northern Mariana Islands Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Palau Rhode Island South Carolina South Dakota Tennessee Trust Territories Texas Utah Virginia Virgin Islands Vermont Washington Wisconsin West Virginia Wyoming *

Zipcode: *

Home Phone: *

Other Phone:

Student Email: *

Confirm Email: *

First Campus Choice: -Select One- Excel Center- Gary Excel Center- Hammond Excel Center- South Bend Excel Center- Elkhart *

Second Campus Choice: -Select One- Excel Center- Gary Excel Center- Hammond Excel Center- South Bend Excel Center- Elkhart

Have you ever applied to the Excel Center before? -Select One- Yes No *

Are you listed on any federal or state sexual offender registry? -Select One- Yes No *

What is the native (first learned) language of the student? -Select One- Achinese Arabic Cantonese English French Japanese Mandarin (Sichuanese) Russian Spanish Other *

What is the predominant (most often spoken) language of the student? -Select One- Achinese Arabic Cantonese English French Japanese Mandarin (Sichuanese) Russian Spanish Other *

What language is most often spoken in your home? -Select One- Achinese Arabic Cantonese English French Japanese Mandarin (Sichuanese) Russian Spanish Other *

Name: *

Date: *