Request for Information

Prospective Student Information

Student First Name

Student Last Name

Student Email Address

Student Preferred First Name (if different than what is listed above)

Student Birthdate

Student Gender

Mobile Phone

I opt in to receive text messages from regarding events, visitation, or application updates. (Standard messaging rates may apply.)

Yes

Student Mailing Address

Country

Street

City

Region

Postal Code

Academic Information

When would you like to enroll?

What is your intended level of study?

Area of Interest

Program of Interest

Pharmacy Interest

Law Interest

School Information

Current High School or Most Recent High School

Current College or Most Recent College

Parent / Guardian Information

Parent / Guardian Email

Parent / Guardian First Name

Parent / Guardian Last Name

Relation to Student