Special Student Application

Student Information

Last Name: (*)

First Name: (*)

Middle Name: (*)

Maiden Name:

Birthdate (MM/DD/YYYY): (*)

Gender: (*) Male     Female

Contact Information

Address: (*)

City: (*)

State: (*)

ZIP: (*)

E-mail: (*)

Admissions Information

Student Type: (*) High School     Non-Degree Seeking Student

For which term are you applying (*) Fall Interim Spring

Intended Course(s): (*)

Father's Name: (*)

Mother's Name: (*)

Are your parents divorced/separated? Yes     No

If so, with whom do you reside? Mother     Father     Guardian    

Please list both parents' address if divorced or separated:

Father's address:

Mother's address:

Please list the names and relationship of any relatives who have attended Buena Vista University:

List all high schools and colleges attended: (*)

School	Dates attended	Reason for leaving

Optional Fields

Marital Status

Single Married Divorced Separated Widowed Other

Religious Affiliation

Baptist Catholic Disciples of Christ Jewish Lutheran Methodist
Presbyterian Episcopal      Other:

Racial/Ethnic Information:

American Indian Asian/Pacific Islander Black/African American
Mexican American Puerto Rican White Caucasian      Other:

By clicking submit, you agree that the information furnished on this application is complete and correct, and that any deliberate omission or falsification of information may result in denial or dismissal.