Build Your Bright Future

Student Information

Student's First Name *

Student's Preferred First Name (name you would like on your name tag if not your first name)

Student's Last Name *

Preferred pronouns to appear on name tag (optional)

Student's Birthdate *

Mailing Address *

Country

Street

City

Region

Postal Code

Email Address *

Home Phone

Cell Phone *

Academic Information

Current School *

I am a prospective *

College Entry Year *

Intended Major*

Parent/Guardian Information

Relationship*

Parent/Guardian First Name *

Parent/Guardian Last Name *

Parent/Guardian E-mail Address *

Parent/Guardian Mobile Number *

Have you had a parent or grandparent graduate from Susquehanna?*

Yes

No

Please enter the name(s) and grad. year(s) of your alumni relatives below:

Will any of these relatives be joining you for the event?

Yes

No

Visit Information

Number of Guests (not including the student)*

Offering for Aug. 7 event only:
Are you interested in taking an optional early bird campus tour? (Arrive at 9:45 a.m. for early registration)

Yes

No

Special Accommodations (Food Allergies, Accessibility, etc)

Application Management