Early Start Certiciate/6-week Course Application 2025-2026

Student Information

First Name*

Preferred Name

Middle Name*

Last Name*

Student Personal Email*
(please do not use your high school email address)

Social Security Number (please omit dashes)*

Date of Birth*

Gender*

Female

Male

Undeclared

High School

High School CEEB (Hidden)

High School Level of Study (Hidden)

What year do you graduate high school?

If going to college, what academic year do you plan to start?

If going to college, what semester do you plan to start?

Enrollment Classification*

If going to college, what academic program would you pursue:*

Department (hidden)

Contact Information

Permanent Address*

Country

Street

City

Region

Postal Code

Student Cell Phone*

Would you like to receive text messages, at this number, from Indiana Tech?

Yes

No