First Name (required)

Middle Name

Last Name (required)

Mailing Address (required)

City (required)

State (required)

Zip Code (required)

Phone Number (required)

Email ID (required)

Current High School/College (required)

School college attending in the Fall of 20____ (required)

School/College attending as (required)
FreshmanSophomoreJuniorSenior

Grade Point Average (GPA) on a 4.0 Scale (attach proof of GPA) (required)

ACT/SAT Score (attach a copy of ACT/SAT score) (required)

Choice of course/major subject of study (required)

Parents/Legal Guardian Full Name (Father) (required)

Parents/Legal Guardian Full Name (Mother) (required)

Occupation Father (required)

Occupation Mother (required)

Household Income (required)

Siblings (required)

Parent's Address (if different than mailing)

City

State

Zip Code

Respond in no more than 1000 words on how do you think that the course of your choice will benefit humanity? (required)

Respond in no more than 500 words on how can you bring a change to the world? (required)