Registraion

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Gender Female Male

Student Email REQUIRED Please fill out this field. Please enter an email address.

Student Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Local Address REQUIRED Please fill out this field. Please enter valid data.

City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

School REQUIRED CBC Hendrix UACCM UCA Other Please fill out this field.

Year REQUIRED Freshman Sophomore Junior Senior Graduate Student Other Please fill out this field.

Interested in the Connect Retreat? (a retreat for first year students) REQUIRED Yes No Please fill out this field.

Interested in CCM Music Ministry? REQUIRED Yes No Please fill out this field.

Interested in Small Groups?

Check the days you are most available/interested in Small Groups

Mondays @ UCA Tuesdays @ UCA Thursdays @ UCA Mondays @ Hendrix Other/I would like more information

Interested in Graduate & Young Alumni events? Yes No

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Parent(s) Name REQUIRED Please fill out this field. Please enter valid data.

Alumni CBC Hendrix UACCM UCA Other

Parent Street Address REQUIRED Please fill out this field. Please enter valid data.

City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

Parent Contact Number REQUIRED Please fill out this field. Please enter a phone number.