College Connection Ministry

Registration/Information Sheet

By submitting this form, you are enrolling a college student in the Long's Chapel Connection for the identified academic year only. Please resubmit if there are changes during the academic year. For further information, contact news0303(at)bellsouth.net.

Year Beginning in Fall of:

Student Name:

College Mailing Address:

College Street Address (if different):

Dorm/Apartment Name/Number:

Cell No. (Calls after 9pm if desired.)

Email Address:

Birthday (MM/DD/YY):

Year of Study:

Other:

Expected Graduation (MM/YY):

Institution of Study:

Major:

Academic Year Starts In:

Fall Break (from MM/DD to MM/DD):

Fall Semester Exam Dates (from MM/DD to MM/DD):

Christmas Break (from MM/DD to MM/DD):

Spring Break Dates ((from MM/DD to MM/DD):

Spring Semester Exams (from MM/DD to MM/DD):

Do you wish to receive the monthly newsletter?

Do you wish to receive the weekly bulletin by email?

Student's Interests Hobbies:

Student's Employment

Student's Envolvement on Campus or Community:

Parent(s) Name:

Parent's Address:

Parent Contact Phone Number: