ULtra Presents L.E.A.D for the Future with School of Nursing

Prospective Student Information

Student First Name*

Student Last Name*

Do you have a preferred first name (different from your legal name) that you would like to provide us?*
Note: UofL uses preferred name in communications to you via text, email and in print mailed to your address. We also use it when communicating with parents/guardians. If you are not comfortable having some people know this first name, you do not need to share it at this time.

Yes

No

Mailing Address

Country

Street

City

Region

Postal Code

Student Preferred Name

Student Birthdate*

Mobile Phone*

Would you like to receive text communications/reminders about your upcoming visit (carrier data rates may apply)?

*

Would you like to receive text communications/reminders about your upcoming visit (carrier data rates may apply)?

*

Yes

No

Personal Email Address*
Communications about the event will be send to this email address

Are you a current ULtra student?

Yes

No

KCTCS Email

KCTCS ID

Academic Information

Current school level of study*

College Level

High School Level (only report school you are graduating from)

Current School*
Please type your school name, then scroll and SELECT your school from the drop down to ensure a match with our records. Typing in a city or abbreviated state (ex: Sacred Heart KY) can also help narrow your search.

Intended Major*

Expected Graduation Date*

Registration Details

If more than one student will be attending the event, please submit a separate form for each student.

Total attendees registering*
The total number of attendees includes the student and a maximum of 1 guest.

Guest Email Address
This individual will receive a copy of your confirmation email and visit details.

Do you or your guest(s) have any special dietary restrictions?*

Yes

No

Please describe your dietary restrictions in detail:

Do you or your guest(s) require any special accommodations to participate in this event (ASL interpretation, physical accommodations, etc.)?*
Language/ASL interpretation requests must be made at least 2 weeks in advance of the visit. Mobility requests must be made at least 5-7 business days in advance of the visit.

Yes

No

Please describe your accommodation needs in detail: