Application for Military Science Program (Royals Leadership Challenge) |

Company

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Name:*

First Middle Last

Note: This information is being required as a matter of legal reporting requirements applicable to 91��. It will not be taken into account in any admission or academic decision, nor in the administration of any program at the University.

Birthdate:*

Last 4 digits of your SSN:

Ethnicity:

Gender:

Male
Female

Contact Information

Student Email:*

Parent Email:*

Address*

Street Address Address Line 2 City State ZIP Code

Main Phone:*

Work/Cell Phone:

Citizenship & Immigration

Are you a citizen of the United States?*

Yes
No
Permanent Resident

If presently in the U.S.:

What Visa status do you hold?*

Current I-94 Number:*

Academic Information

I plan to begin taking classes...

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Semester:

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Year

High School or Homeschool Graduation Date:*

High School or Homeschool Name:*

High School or Homeschool Location:*

City State

Are you currently a member of a Junior Reserve Officers Training Corps Program (JROTC)?*

Yes
No

What is your JROTC Program Branch Affiliation?

U.S. Army
U.S. Air Force
U.S. Navy
U.S. Coast Guard
U.S. Marine Corps

Have you applied for admission to 91�� as a degree student?*

Yes
No

Semester:*

Year*

Have you been dismissed and/or suspended from any high school or homeschool for any reason?*

Yes
No

If yes, please explain:*

How did you hear about Regent?

Acknowledgement:*

By checking this box I verify that upon admission into the Military Science Program, 91�� is authorized to register me for the next available section of Introduction to Military Culture (MILS 110). I ensure that all aspects of my student account are paid by the first day of classes or that I will have the Tuition Installment Plan (TIP) set-up.

I Agree

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