Pioneer Preview Registration Form

Event Information

Pioneer Preview Dates * Please select one of the following dates.

Total Number of Individuals Attending *

First Name *

Middle Initial

Last Name *

Address 1 *

Address 2

City *

State *

Major/Area of Interest * Please select one of the following areas.

ZIP Code *

Gender *

Race/Ethnicity

Other Ethnicity If you selected "Other" above, please specify here.

Phone Number * Please include your area code

Email

Confirm your email address

Date of Birth * mm/dd/yyyy

What type of student will you be if you enroll at UWP? *

Name of High School * If you are home schooled or have received a GED, please indicate that in the space provided.

City of High School *

County of High School *

State of High School *

Year of High School Graduation *

If you plan to be a transfer, please list the school(s) you will be transferring from.

Special accommodations needed? * (i.e. wheelchair accessibility, interpreter, etc.)

Please specify needs if special accommodations requested.

How would you like to receive your confirmation information? * If you are registering within a week of the event, we will email the confirmation.