2022 Pre-College Access Institute, Sponsored by Walmart

High School Student Program Registration Form

Student Information

*required fields

Student First Name*

Student Middle Name

Student Last Name*

Student Email Address*

Confirm Student Email Address*

Student Mobile Phone* (By providing your mobile phone number, you agree that Montclair State University may periodically send you SMS text messages)

Student Birthdate*

Student Mailing Address*

Country

Street

City

Region

Postal Code

Are you Hispanic or Latino/a/x?

Yes

Regardless of your answer to the prior question, please check one or more of the following groups in which you consider yourself to be a member:

Student Academic Information

Please click the school you are currently attending/have attended from the autosuggest list.

Current/Last School Attended*

Please upload a copy of your high school transcript. An unofficial copy is acceptable.

When do you plan to enter college?*

Program of Interest*

Music Concentration

Are you interested in Teacher Education?

Yes

Are you interested in any pre-professional programs?

Pre-Law

Pre-Med

Parent/Guardian Contact Information

Preferred Language

Parent/Guardian First Name*

Parent/Guardian Last Name*

Parent/Guardian E-mail Address*

Parent/Guardian Mobile Phone* (By providing your mobile phone number, you agree that Montclair State University may periodically send you SMS text messages)

Do you want to add a second parent/guardian?

Yes

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian E-mail Address

Parent/Guardian Mobile Phone (By providing your mobile phone number, you agree that Montclair State University may periodically send you SMS text messages)

Program Interest

Why do you wish to attend this program? What do you expect to learn? (Max 200 words)