BRIDGE PROGRAM ENROLLMENT FORM

1.

Student Information

First Name
Middle Name
Last Name
Gender
Date of Birth	Day	Month	Year (YYYY)
Phone
Permanent Address
Mailing Address (If different from above)
City
State
Zip Code
Email Address
Completed number of Midland Technical College credits (if none, list 0)
Anticipated # of Midland Technical College credits before transferring
What is your major at Midland Technical College?

2.

School Information

High School graduation/GED Completion date
Anticipated entry term at Benedict College
Program:
Anticipated Benedict College major
Cumulative College GPA

3.

Advisor Verification

4.

What support services would help you succeed?

	If other, please specify

*5.

STATEMENT OF INTENT

I understand the expectations of the Bridge Program and agree to participate in required advising and program activities.

By electronic signing and submitting this form, I acknowledge that I have read, understood, and agreed to its terms and conditions outlined above.

Printed Name

BRIDGE PROGRAM ENROLLMENT FORM - Benedict College