Name:     Birth Date: 

City:        State:         

Phone:   e-Mail:          

GPA:       ACT:       Contact me by: Phonee-Mail

Status: High School Student High School Graduate College Freshman College Sophomore Current Military Other    Other:

U.S. Citizen?  Yes No       Military Experience: None JROTC Prior Service

Do you compete in team sports or athletic competitions?   Yes No

Do you hold a leadership position at school or elsewhere? Yes No