Eastern Early College Student Registration

First Name*

Middle Name

Last Name*

Mobile Phone Number*

Birthdate*

Email Address*

Parent/Guardian Email Address*

Current High School

CEEB

Mailing Address*

Country

Street

City

Region

Postal Code

Preferred Pronouns (Optional)

Social Security Number* (All students who have a SSN are required to submit this. However, if a student does not have a SSN, this field can be left blank)

Sex assigned at birth (Optional)

Gender Identity (Optional)

Are you Hispanic or Latinx?

Yes

No

How likely are you to apply to be a full-time student at Eastern?

Ethnicity

Year of High School Graduation

Current School Attending*

IMPORTANT - CTRL + CLICK FOR MULTIPLE!: Choose all courses for which you are requesting to register

NOTE: PLEASE SUBMIT FORM ONLY ONCE EVEN IF SELECTING MULTIPLE COURSES. By submitting this form, I agree to have an Eastern account created for me and be enrolled in the classes that I have chosen above. Rosters will be verified with high school staff for final enrollment.

I agree

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