Jessamine Connection Application

An * indicates a required field.

Student Information

Has this student previously applied to Asbury University?

Yes

* First Name:

Middle Name:

* Last Name:

Preferred Name:

* Birthdate:

* Sex:

Female

Male

Social Security Number:

Student Contact Information

Email Address:

* Mailing Address

Country

Street

City

Region

Postal Code

Student Telephone Number:

Emergency Contact

* Emergency Contact First Name

* Emergency Contact Last Name

* Relationship Type:

* Emergency Contact Phone Number:

Emergency Contact Address

Country

Street

City

Region

Postal Code

Academic Information

High School Name:

* Semester Requested:

Course 1 Name, Code, and Section:

Course 2 Name, Code, and Section:

Course 3 Name, Code, and Section:

Legal Agreement

* All the information contained on this application is true and correct to the best of my knowledge. I understand that I am responsible for arranging the forwarding of official transcripts of all schools I have attended or am attending and official test scores as required. Such documents become the property of Asbury University and will not be returned to me.

Yes, all of the information provided is correct.

* Please type your full name to verify your agreement to both of these statements:

Asbury University does not discriminate on the basis of race, color, gender, age, national or ethnic origin, or disability in the admission of students, educational policies and programs, employment policies, and activities. In addition, Asbury University does not discriminate on the basis of religion in the admission of students and student access to educational programs.

Hidden: Citizenship = United States