Millburn High School College Night

Biographical Information

First Name

Preferred Name

Last Name

Birthdate

Email Address

Home Phone Number

Mobile Phone Number

I consent to be contacted by Wagner College at the mobile number provided below.

Yes

No

Mailing Address

Country

Street

City

Region

Postal Code

School Information

Current School or College

Current School CEEB Code

Entry Term

Student Type

Intended Major

Are you interested in participating in our Division 1 Athletic program?

Yes

No

Are you interested in one of the following co-curricular activities?