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Readmission Form for Returning Students

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* = Required Field
 * Anticipated Enrollment:  
 Fall = August to December
 Spring = January to May
 Summer = June to August
    SSN:    (Example: 999-99-9999)
 * First Name:    
 * Last Name:    
 * Phone:   (Example: 123-456-7890)
 * Email:  
 * Birthdate:                                     
 * Gender
 * Program of Study:  
 * Address:  
 * City:  
 * State:    
 * Zip Code:  
This information is requested solely to determine compliance with federal civil rights laws, and your response will not affect consideration of your registration. By providing this information, you will help assure that this program is administered in a non-discriminatory manner. 
 * Are You Hispanic or Latino (Or are You of Spanish Origin)?

 * Are You from One or More of the Following Racial Groups?
    Select ALL that apply from the first five check boxes OR Select I Choose not to Respond check box ONLY.