Request for Information

*If you are an international student, please email international@laroche.edu to request more information. You are an international student if you are not a United States Citizen and are not a Permanent United States Resident/Green Card holder, U.S Refugee or Asylee, DACA, Undocumented, Deferred Enforced Departure, or Temporary Protected Status.

Personal Information

Student First Name

Student Middle Name

Student Last Name

Suffix

Gender at birth

Birth Date

Country of Citizenship (if you’re a dual citizen of the United States, please select United States)

Are you a permanent United States Resident/Green Card holder?

Yes

Social Security Number (optional)

Are you any of the following?

Please email international@laroche.edu to request more information. You are an international student if you are not a United States Citizen and are not a Permanent United States Resident/Green Card holder, U.S Refugee or Asylee, DACA, Undocumented, Deferred Enforced Departure, or Temporary Protected Status.

Contact Information

Permanent Address

Country

Street

City

Region

Postal Code

Is your mailing address different?

Yes

Mailing Address

Country

Street

City

Region

Postal Code

Student Primary Phone Number

Phone Type

Would you like to receive text messages?

Yes

Student Secondary Phone Number

Phone Type

Would you like to receive text messages?

Yes

Student Email Address

Enrollment Information

Will you be entering as an Undergraduate or Graduate student? (If you're currently still in high school select Undergraduate.)

Will you be a Freshman or Transfer student? (Select Freshman if you're still in high school.)

Planned Enrollment Term

Fall (August Start)
Spring (January Start)
Summer (May Start)

Intended Major

Please note: Degree completion programs are designed for individuals who have some college credits but haven't finished their degree. This program requires previous licensure. Please double check admission requirements prior to applying.

Full time or Part time

Previous College/University Information

College/University Name

College/University CEEB

High School Information

Are you a home school student?

Yes

In the High School Name field below, please type in "969999" and select "Home School"

High School Name

High School CEEB

High School Graduation Year

Parent/Guardian Information

Do you want to provide parent information?

Please choose type

Parent First Name

Parent Last Name

Parent Cell Phone Number

Parent Email Address

Would you like to add another parent/guardian?

Please choose type

Parent First Name

Parent Last Name

Parent Cell Phone Number

Parent Email Address