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Graduate Assistant Registration

Welcome, graduate assistants. We are thrilled that you are interested in joining us in a role of service this summer.

Please complete the following information carefully. Note that you will need your parents' help on a few areas, so you will want to complete this application while they are around to provide you with assistance.

For all phone numbers, use (xxx) xxx-xxxx format.

Last Name
 A value is required.
Age
 A value is required.
First Name
 A value is required.
Current Grade
 A value is required.
Current School
 A value is required.
Gender
 Please select an item.
       
Home Address
 A value is required.
Your E-Mail
 A value is required.Invalid format.
City
 A value is required.
Parent E-mail
 A value is required.Invalid format.
ZIP
 A value is required.Invalid format.
Home Phone
A value is required.Use (xxx) xxx-xxxx format.
Number of Years as a Scholar at DECATS)
 A value is required.
Your Cell Phone
 A value is required.Use (xxx) xxx-xxxx format.
       
Mother's Name
 A value is required.
Father's Name
 A value is required.
Mother's Occupation
 A value is required.
Father's Occupation
 A value is required.
Mother's Work Phone
 A value is required.Use (xxx) xxx-xxxx format.
Father's Work Phone
 A value is required.Use (xxx) xxx-xxxx format.
Mother's Cell Phone
 A value is required.Use (xxx) xxx-xxxx format.
Father's Cell Phone
 A value is required.Use (xxx) xxx-xxxx format.
       
Emergency Contact 1 Name
 A value is required.
Emergency Contact 2 Name
 A value is required.
Phone
 A value is required.Use (xxx) xxx-xxxx format.
Phone
 A value is required.Use (xxx) xxx-xxxx format.
Relationship to You
 A value is required.
Relationship to You
 A value is required.
       
Doctor's Name
 A value is required.
Insurance Carrier
 A value is required.
Doctor's Phone Number
 A value is required.Use (xxx) xxx-xxxx format.
Policy / Group Numbers
 A value is required.
Preferred Hospital
 A value is required.
Carrier Phone Number
 A value is required.Use (xxx) xxx-xxxx format.
Preferred Hospital Phone
 A value is required.Use (xxx) xxx-xxxx format.    

     
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