Personal Information Birth Date First Name Last Name Street Address City State - None -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code Home Phone Number Cell Phone Number Email Address First Term at North Central Anticipated Major Career Aspiration Name of High School Will you be an on campus resident or commuter? Resident Commuter Are you participating in the College Scholars Honors Program? yes No Not Sure Are you participating in the Cardinal Athletic Band, Color Guard, Dance Team or Cheer Team? Yes No Not Sure Are you planning on participating in any extra-curricular activities at North Central? If so, which ones? Are you competing in any NCAA recognized intercollegiate athletic teams for North Central College? (i.e. football, soccer, track). If so, which one(s)? Please list any food allergies or dietary needs during the program Please list any medical concerns we should be aware of during the program Please list any accommodations needed during the program (i.e. physical or language restrictions) Please indicate your t-shirt size - None -Men's SmallMen's MediumMen's LargeMen's XLargeMen's XXLargeWomen's SmallWomen's MediumWomen's LargeWomen's XLargeWomen's XXLarge Please answer the following questions How do you think you would benefit from participating in the Premier Scholars Program? What type of challenges have you had to overcome in your life thus far? What do you hope to accomplish (career/life goals) after you complete college? Please explain any possible schedule conflicts between Wednesday, August 23 and Tuesday, September 5 Is there anything else you would like the Premier Scholars Program staff to know about you?