Application Name * First Name Last Name Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Date of Birth MM DD YYYY SSN Program Selection Group Programs 1:1 Consultations Career Assessment College Connection Camp Segue Socials Segue Getaways Please list any colleges/universities attended. Please list any high school(s) attended with graduation dates. Diagnosed Learning Difference or Social Challenge (please select if applicable): ADHD Anxiety Disorder Autism Spectrum Disorder Bipolar Disorder Communication Disorder Dyscalculia Dysgraphia Dyslexia Executive Function Disorder Non-Verbal Learning Disability OCD Other If Other, please list: Please list any additional personal information which is pertinent to your educational or career success: Work Experience (Paid or Volunteer): Personal Goals (if considered) for the next 3 years: Person Responsible for Registration Decision: First Name Last Name Person Responsible for Financial Payment: First Name Last Name Signature * My signature below affirms that all of the information contained in this registration packet is correct, complete, and honestly presented. The electronic signatures below and their related fields are treated by Segue Center like a physical handwritten signature on a paper form. First Name Last Name Date MM DD YYYY Parent/Guardian (if applicable) First Name Last Name Date MM DD YYYY Thank you!
