American Indian Graduate Center College Readiness Program Registration - North Dakota

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* 1. What is your Name?

First Name

Last Name

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* 2. What is your gender?

Female

Male

Other (please specify)

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* 3. What is your address - State?

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* 4. What is your address - City & Zip Code?

City:

Zip Code:

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* 5. What is your email address?

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* 6. What is your phone number with area code (xxx)xxx-xxxx?

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* 7. What is the name of your High School?

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* 8. What is your High School's State?

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* 9. What is your Tribal affiliation (enter "n/a" if not applicable)?

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* 10. Which best describes you?

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* 11. How did you hear about our College Readiness Program?

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* 12. Will your parent(s) or guardian(s) be attending?

Yes

No

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* 13. What is your parent(s) or guardian(s) name?

First Name

Last Name

First Name

Last Name

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* 14. What is your parent(s) or guardian(s) email address?

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* 15. What is your parent(s) or guardian(s) phone number?

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* 16. Are you under 18?

Yes

No

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* 17. The American Indian Graduate Center has my permission to use my or my child's photograph publicly to promote the organization. I understand that the images may be used in print publications, online publications, presentations, websites and social media. I also understand that no royalty, fee or other compensation shall become payable to me by reason of such use. By checking this box and typing my name below, I am electronically signing this Photo Release.

I agree

I don't agree

Please type your name for electronic photo release