Kentucky Council on Postsecondary Education
2014 Academically Proficient High School Junior and Senior Diversity Conference

1. Student first name:
2. Student last name:
3. Street address:
4. City:
5. State:
6. Zip code:
7. Phone number (with area code):
8. Gender:
9. Student email address:
10. School:
11. Classification (as of Fall 2014):
12. What is your future major/area of interest?
13. Parent(s)/Guardian(s) names:
14. Parent(s)/Guardian(s) work phone:
15. Will your parent(s) or guardian(s) attend the conference with you?
16. Do you plan on requesting overnight lodging at Murray State University? (If yes, please complete the Housing Form listed on the main conference page.)
17. If the student or parent(s)/guardian(s) need special accommodations (I.e. handicapped accessible rooms or vegetarian meals) during the conference, please specify below.
18. Will the student or the parent(s)/guardian(s) need transportation to the conference? (Transportation will be arranged on a limited basis.)
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