Thank you for your interest in the STEM Student Conference. Please fill out the form below to confirm your registration. All fields in bold are required.

First Name:		Last Name:

El Camino College Student ID #:		Mailing Address:

City:		Zip Code:

Best Contact Phone Number:		Ethnic & Racial Survey (Optional):

Email:		Are you (Optional): Male Female

I. BACKGROUND

Are you the first person in your family to go to college?		Yes	No

Have you applied for any financial aid?		Yes	No

Are you planning to work while attending college? If so, how many hours per week?		Yes	No
II. GOALS

Major: or most likely Major(s) if undecided:

Educational Goal(s): (check all that apply to you)	Certificate	AA/AS Degree	Transfer for BA/BS Degree
	Masters Degree	PhD	Other

If you plan to Transfer, what are your top three university choices?
1.	2.	3.

If you could choose three careers, what would they be? (Don't think about grades, skills, formal education or family resources at this time.)
1.	2.	3.

If you are a student with a disability and require any accomodations, such as large print, Braille, or interpreting services, please indicate the accomodation you are requesting here:

I authorize communication from El Camino College through email:	Yes	No

I release the use of event photographs for publicity purposes: Yes No

Student Signature(type in your name in the box provided): Date:

16007 Crenshaw Blvd. Torrance, CA 90506
Phone: 1.310.532.3670 Toll Free:1.866.ELCAMINO (1.866.352.2646)

Last Updated On: 9/15/09