Lasallian Collegian Registration Form

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* 1. First Name

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* 2. Last Name

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* 3. Email address

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* 4. Best contact phone number

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* 5. Best mailing address

Address

City

State

Zip Code

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* 6. High School Attended

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* 7. Year of High School Graduation

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* 8. Where are currently attending college? Year?

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* 9. Please let us know why you are interested in serving as a Lasallian Collegian?

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* 10. Do we have your permission to publish your name and school in an on-line Collegians directory?

Yes

No