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Applicant and Family Information
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* Indicates required question
Email
*
Your email
Date
MM
/
DD
/
YYYY
First and Last Name of Applicant
Your answer
I give Misericordia University my permission to take photos/video of my child for promotional purposes
*
Yes
No
If you are completing this application on behalf of the applicant, please describe your relationship.
Parent
Guardian
Care Giver
Other
Mailing Address of the Applicant (include street name and number, city, state, and zip code)
Your answer
Applicant's Home Phone Number
Your answer
Applicant's Cell Phone Number
Your answer
Applicant's Email Address
Your answer
Applicant's Date of Birth
MM
/
DD
/
YYYY
Race (optional): Please indicate how you identify yourself
American Indian or Alaska Native (including all Original Peoples of the Americas)
Asian (including Indian subcontinent and Philippines)
Black or African American (including African and Caribbean)
With (including Middle Eastern)
Ethnicity (optional): Please indicate how you identify yourself. Hispanic/Latino
Yes
No
Clear selection
Are you a US Citizen
Yes
No
Are you your own legal guardian?
Yes
No
Unsure
If No, please provide the name and relationship of your legal guardian
Your answer
Mother/Guardian Name
Your answer
Mother/Guardian Address
Your answer
Mother/Guardian Employer/Occupation
Your answer
Mother/Guardian Work Phone
Your answer
Mother/Guardian Email Address
Your answer
Mother/Guardian Cell Phone
Your answer
Father/Guardian Name
Your answer
Father/Guardian Address
Your answer
Father/Guardian Employer/Occupation
Your answer
Father/Guardian Work Phone
Your answer
Father/Guardian Email Address
Your answer
Father/Guardian Cell Phone
Your answer
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