Historically Black Colleges and Universities Tour Application

Application must be received by Monday, February 25, 2008

Student’s Name:
Email Address:
Parent(s)/Guardian’s Name:
Home Address (No P.O. Boxes):       Street Address                                Apt. #
City	State	Zip Code
Country
Phone Numbers: (area code first; no dashes or spaces)
Home		Parent's Work
Mobile Phone	Contact Person	Emergency Phone
Grade in School : (4.00 Scale)		Cumulative GPA: (4.00 Scale)
Church and Pastor’s Name:
High School Attending:
Community Involvement:
Extracurricular Activities:
I hereby certify the information provided in this application is, to the best of my knowledge, true and correct. I have not knowingly withheld any facts that would jeopardize consideration of this application, and can provide documentation to prove I am legally authorized to work in the United States. RainbowPUSH and PUSH Excel may use all information obtained from my entry for marketing purposes.
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