* indicates required information

Your First Name* :
Your Last Name* :

Did you attend the U?:    no      yes      
If so, when?:  

Your E-Mail Address (for confirmation purposes only* ): 

Relationship to the Student* :  

Student's First Name* :

Student's Last Name* :

Student's Gender* : Male Female

Student's Date of Birth:

Student's Mailing Address* :

City* : State* : Zip* :

Student's Phone Number (xxx-xxx-xxxx): 

Student's Cell Number (xxx-xxx-xxxx):  

Student's E-Mail Address

School student is currently attending or last attended* :

Student's expected high school or college graduation year* :  select a year 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Has this student already submitted an admission application?* : no      yes

Student's anticipated entry year to the U:     Fall       Spring     Summer

Student's anticipated entry year to the U: select a year 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Student's academic interest(s):

Student's Other Interests (extracurricular activities):

Thank you for referring this student to the University of Utah!  If you have any questions or concerns, contact Paulmichael Maxfield at 801-585-1998 or pmaxfield@sa.utah.edu.