Name: _____________________________ Social Security #: _____________________ Mailing Address: _________________________________________________________ Date of Birth: ______________________________ Phone : ________________________ Parent Name (Must be UTHSC-H Employee): ___________________________________ High School attending: _____________________________________________________ Address: _________________________________________________________________ _________________________________________________________________________ High School Counselor: ____________________________________________________ Phone #: _________________________________________________________________ University
or Technical School you
plan to attend: Address: _________________________________________________________________ Begin date: ________________________________________________________________ The following must accompany your Completed application:
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