Please submit this form no later than January 9, 2009.


First Name*:
Last Name*:
Address:
City:
State:
Zip:
Home phone:
Cell phone:
E-mail Address*:
In an emergency,
who should be called?:
Relationship:
Phone:
Parent/Guardian
names:
Parent/Guardian
e-mail address:
Name of Health
Insurance Co.:
Phone:
Policy Number:
Group Number:
Name of Insured:


Please provide the following information about your hometown newspaper so that news of your Wagner successes can be forwarded:

Name of newspaper:
Contact person
at newspaper:
Address of newspaper:
City:
State:  
Zip:  
E-mail address
for newspaper:
Fax for newspaper:
Phone for newspaper:


The following questions are designed to help us get to know you better. Please take your time in answering these questions.

1. List all clubs and organizations in which you participated through high school:


2. List all honorary memberships or awards which you have received while in high school:


3. List participation in community and/or religious activities:


4. List all work experience during the last four years:


5. Please consult the list of Wagner's student clubs and organizations (on page 7 of the First Year Guide) and indicate from the following selections those activities in which you have an interest:

Student Government Association

Clubs/Organizations   ( Please specify ):



Academic Groups   ( Please specify ):



Intramurals   ( Please specify ):



Student Publications
 
Kallista (yearbook)     Wagnerian (newspaper)     Nimbus (literary magazine)
Please submit this form no later than January 9, 2009.