Southeastern High School: Student Info

Please enter information about the student. Required fields are marked with a *.

Student Information

First Name *
Middle Name
Last Name *
Suffix (Jr., Sr., Etc.)
Gender *	Male Female
Date of Birth *	You must be at least 16 years to enroll in this program
Ethnicity
Home Telelphone *
Other Telelphone
e-Mail Address *

Home & Mailing Address

Home Address Street 1 *
Street 2
Street 3
Street 4
City *
State *
ZIP / Postal Code *
Country *
My Home Address is the same as my Mailing Address
Mailing Address Street 1 *
Street 2
Street 3
Street 4
City *
State *
ZIP / Postal Code *
Country *

All fields marked with a * are required and must be filled in before you can continue.