Application for Online Classes Students

Please fill out all required information. If the "Apply Online!" button will not allow you to submit the form, check that all required fields are filled out and that the format of information is correct. Required fields with missing information and fields with invalid formatting will be outlined in red.

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General Information

Social Security Number

- -

Date of Birth (required)

/ /

Enrollment Term (required)

Gender (required)

Male | Female

Are you a veteran or on duty with the US armed forces?

Yes | No

Name (first and last name are required)

Preferred Name

Other Name

Country of Residence (required)

Mailing Address (required)

City (required)

State (required)

Zip Code (required)

County

Home Phone

( ) -

Cell Phone

( ) -

Text Messaging


Carrier:

Email Address

Extracurricular, Personal & Volunteer Activities

List any organizations and activities in which you have participated during the past three years:

Activity:
Grades Involved:
Hours a week:
Weeks a year:
After typing the information in the corresponding fields, click the "add" button to add the activity to the list. To remove an activity from the list, just select it, and then click on the "remove" button.

Enrollment Information

Program of Study (required)

Optional Information

Marital Status

Single | Married | Divorced | Widowed

Do you have any dependents?

Yes | No

Religious Affiliation

Race / Ethnicity

Are you being recruited by a Brescia Coach?

Yes | No

Academic Background

High School

Address

City

State

Zip Code

Graduation Date

/ /

Have you previously applied to / attended Brescia University?

Yes | No

Have you previously attended any college or university? (required)

Yes | No
I agree to adhere to the rules and regulations of the University and certify that all statements in this application are true. I understand that any misrepresentation of the information will make me ineligible for admission to Brescia University or subject to dismissal once admission has been granted.

Brescia University does not discriminate on the basis of race, color, sex, religion, handicap, age, gender preference, national or ethnic origin in the administration of our education policies, admission policies, scholarship and loan programs, athletic activities or other school-administered programs or policies. As a church related college, discrimination of any kind is incompatible with our mission.