Family Life Consultant Program Sign Up Form Please enable JavaScript in your browser to complete this form.Name *FirstLastAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Emergency ContactName *FirstLastRelationship *Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Universities that are recipients of federal dollars are required by the Federal government to solicit certain demographic information to meet federal reporting requirements. Applications are requested to provide the following information voluntarily. This information will not be utilized in a discriminatory manner.Nation of CitizenshipRace / OriginAmerican Indian or Native AlaskanAsian or Pacific IslanderThird ChoiceAfrican AmericanHispanicWhiteNative LanguageReligionGenderMaleFemaleAre you a veteran of the U.S. Military?YesNoDate of BirthMM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920This application is for enrollment as:First Time StudentFormer Student Returning (FSR) Which campus do you seek admission?Victorville, CAManassas, VAOn-lineIf your records have been expunged pursuant to applicable law, you are not required to answer yes to the following questions. If you are unsure whether to answer yes, we strongly suggest that you answer yes and fully disclose all incidents to avoid any risk of disciplinary action or revocation of your offer of admission.Are you currently or have you ever been charged with or subject to disciplinary action for scholastic or any other type of misconduct at any educational institution? *YesNoPlease provide the names of people in your immediate family who have attended our Family Life Consulting training.NameFirstLastRelationshipNameFirstLastRelationshipExtracurricular, Personal and Volunteer ActivitiesExtracurricular ActivitiesList your organizations, position, description of the activity, and hours per week of involvement.Talents and AwardsList each, a description, the level, and number of years of involvement.Community Service WorkList the type of work, your role, and hours per week of involvement.EmploymentList the job, your title, description, hours per week, and dates of employment.Attach an additional Word, PDF or text document if necessary. Click or drag a file to this area to upload. Do you have family obligations that keep you from participating in extracurricular activities?NoYes, I have to work to supplement family income. Yes, I provide primary care for family member(s). OtherIf yes or other, please describe:For Non-U.S. Citizens OnlyCity and Country of BirthWhat is the status of your VISA?I currently hold oneI am applying for oneWhat type of VISA?F2J1J2NoneOtherIf otherI-94 Expiration Date (MM/YYYY)If you are a permanent immigrant, enter the alien registration number shown on your I-551 form:Which institution issued your last I-20?Did you attend?YesNoPlease attach a photo of your Alien Registration card. Click or drag a file to this area to upload. AgreementI understand that this application is for admission only for the term indicated. I agree that I am bound by the University’s regulations concerning application deadlines and admission requirements. I agree to the release of any transcripts and test scores to this institution, including any SAT, Achievement Test, and ACT score reports. I certify that this information is complete and accurate. I understand that making false or fraudulent statements within this application or residency statement will result in disciplinary action, denial of admission and invalidation of credit or degrees earned. If admitted, I agree to abide by the policies of the Board of Regents and the rules and regulations of the University. Should any information change prior to my entry into the University, I will notify the Office of Admissions. I understand that the application fee I submit with this application is a non-refundable fee.Do you understand and agree to the terms listed above? *Yes, I understand and agree to the terms listed above. Events, activities, programs and facilities of the University are available to all without regard to race, color, marital status, sex, religion, national origin, disability, age, Vietnam or disabled veteran status as provided by law and in accordance with the University’s respect for personal dignity.NameSubmit
