Register for April 17, 2009

By filling out this form, you will be registered for the
CHOICES Open House on April 17th, 2009.

Student ID (This is a nine-digit number which can be found on the invoice which came with your admit letter.)

First Name

Middle Name

Last Name

Date of Birth

Select Month January February March April May June July August September October November December Select Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Select Year 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975

Do you have special needs related to a disability? No Yes

Please Explain Your Disability Needs