Personal Information

First Name  

Last Name  

Address  

City  

State   AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

ZIP  

Date of Birth  

Gender   Optional

Male
Female

Your E-Mail Address   You must use your Live@York email account

Home Telephone   Enter your number 718-XXX-YYYY

Alternate Telephone   Please enter your number 718-XXX-YYYY

Preferred Method of Contact  

Email
Phone
US Mail

Immigration Status   US CitizenPermanent ResidentVisa HoldersOther

Academic Status  

Entering Student
Current Student
Graduate

Activities

Are you on any athletic teams?

yes
no

If So What Team

Are you a member of the York College Student Government?

yes
no

Position Held

Community Service/Volunteer Work Please list any that you have participated in.