Coppin State University Office of the Vice-President Scholars Reception Registration (Fields marked in red are required)

Name
First Name		Last Name

Contact Information

Address:

City State Alabama Alaska Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Ontario Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code

Please indicate County (MD residents only) Allegany Anne Arundel Baltimore City Baltimore theCounty Calvert Caroline Carroll Cecil Charles Dorchester Frederick Garrett Harford Howard Kent Montgomery Prince George's Queen Anne's St. Mary's Somerset Talbot Washington Wicomico Worcester

Phone ( ) - ext. Email

Educational Background & Interests
Present High School or College	H.S. Graduation Yr.  Before 2000 2000 2001 2002 2003 2004 2005 2006 2007 2008
I am a: High School Senior High School Junior Prospective Transfer My SAT score is:  My GPA is:
Academic Interest(s): Select at least one (1) but no more than two (2) fields Only the first two selections will be considered To select multiple fields: PC Users - Hold down the CTRL key while selecting Mac Users - Hold down the COMMAND key while selecting	Biology Chemistry Computer Science Criminal Justice Dance Early Childhood Education Elementary Education English General Science Global Studies History Liberal Arts Management Science or Business Mathematics Media Arts Nursing Performing Arts Pre-Dentistry Pre-Engineering Pre-Pharmacy Pre-Physical Therapy Psychology (Applied) Rehabilitation Services Social Science Social Work Special Education Sports Management Urban Arts Production

Program Information

Please indicate the total number of guests (include yourself)