Shamokin Area High School College Fair

First Name

Chosen First Name

Middle Name

Last Name

Birthdate

Primary Country of Citizenship

Mailing Address

Country

Street

City

Region

Postal Code

Email Address

Mobile Number

May we text you?

Yes

No

Phone Number

I am a prospective...

First Year Student

Returning Student

Transfer Student

Most Recent College/University Attended

Do you have a degree?

Yes

No

High School/Secondary School Name

Graduation Month/Year

Do you currently attend a career & technology center (CTC)?

Yes

No

Career & Technology Center (CTC) Name

Academic Area of Interest

Starting Semester