C4

Name

First Name:

Middle Name:

Last Name:

Address

Street Address:

City:

State:

Zip:

County:

Date of Birth

Month:

Day:

Year:

Contact Information

Home Phone:

Alternate Phone:

Email Address:

Ethnic Identity:

African American/Black

Native American

Caucasian/White

Hispanic

Multiracial

Other

Gender:

Male Female

Parent/Guardian Information:

First:

Last Name:

C4 Information:

Current Academic Grade Level:

Anticipated Graduation Date:

Choose a Course:

Course:

Add another class?

Course 2:

Add another class?

Course 3:

Add another class?

Course 4:

Add another class?

Course 5:

Add another class?

Course 6:

Add another class?

Course 7:

Add another class?

Course 8:

Past Classes:

Have you taken dual credit courses through Ivy Tech before?

Yes No

Test:

Please check the test you have taken.

ACT PSAT SAT