BRIDGE PROGRAM ENROLLMENT FORM - Lander University
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Student Information
First Name
Middle Name
Last Name
Gender
Date of Birth
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Month
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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 Lander University
Program:
Anticipated Lander University major
Cumulative College GPA
3.
Advisor Verification
Advisor Name
Contact Information - Phone
Advisor Email
4.
What support services would help you succeed?
Tutoring
Mentorship
Transfer Planning
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.
Printed Name
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