Date:
|
First Name:
|
Last Name:
|
Street Address:
|
City:
|
State:
|
ZIP:
|
E-mail address:
|
Phone Number:
|
Sobriety Date (exact):
(MUST have six months sobriety
to enter program) |
| Term you wish to begin StepUp: |
Spring
Fall
Summer |
| Of what year: |
|
What year are you in college:
First-year student
Sophomore
Junior
Senior
Transfer student |
Do you wish to receive information
on the Center for
Learning and Adaptive Student Services (CLASS) Program:
Yes
No
Note: The CLASS Program provides
a full range of support services for students with documented learning
disabilities, Attention Deficit Disorder (AD/HD), psychiatric disabilities
and physical disabilities. |
| Do you wish to receive an application for admission to Augsburg
College:
Yes
No |
|
|
