EmailMe Form - HBCU Financial Assistance Request Form

Parent/Guardian Name *

First Last

Student Name *

First Last

Street *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Home Phone *

### - ### - ####

Mobile Phone *

### - ### - ####

Email Address *

Education *

	Name of School	Grade	GPA
Current School

Interests *

Possible field of study in college *

Are there other middle school or high school children in your household that may be interested in future tours? *

Yes

No

Cost of Event: $2,300. Inclusive of airfare, charter bus transportation, lodging, meals, and activities.

Please share the amount you can contribute: *

Amount You are Requesting *

Write a 500-word essay responding to the question, why I want to attend the HBCU tour. *