Scholarship/Placement Test Registration Form

All fields in BOLD are required.

Test Date:
(Select One)		 May 12, 2012 - 8:30 AM-12:00 PM
October 12, 2012 - 8:30 AM-12:00 PM
October 27, 2012 - 8:30 AM-12:00 PM
November 10, 2012 - 8:30 AM-12:00 PM
First Name:
Last Name:
Address:
City:
State:
Zip Code:
Phone:
Date of Birth: (mm/dd/yyyy)
Gender: Male Female
Current Grade:
School:
E-mail Address:
Father's First Name:
Father's Last Name:
Father's Daytime Phone:
Mother's First Name:
Mother's Last Name:
Mother's Daytime Phone:
Additional Phone:
Registration fee: $20
Cash or check (payable to STVM) on the day of the test
Type in the code that you see in the image below: