Personal Information

First Name: *

Middle Name:

Last Name: *

Nickname:

Date of Birth: *

Gender:

Female

Male

Race:

American Indian or Alaskan Native

Asian or Pacific Islander

Black, not of Hispanic origin

Hispanic

White, not of Hispanic origin

The Governor's Honor Academy has an equal opportunity policy and does not discriminate on the basis of race, color, natural origin, religion, sex or disability.

T-Shirt Size: *

Address

Street Address or PO Box: *

Apartment/Unit #:

City: *

State: *

Postal Code: *

County:

Contact Information

Home Phone: *

Cell Phone:

Email Address: *

School Information

High School: *

Principal's Name: *

School Phone: *

GPA: *

First 9 Weeks GPA for 11th Grade: *

Will you be a career/technical completer?

Yes

If yes, what is your area of study?

Number of AP/IB courses you have been eligible to take:

Number of AP/IB courses you have taken or are taking:

Family Contact Information

Name(s) of Parents:

Father's Home Phone:

Father's Work Phone:

Father's Cell Phone:

Mother's Home Phone:

Mother's Work Phone:

Mother's Cell Phone: