Online LDZ Application

PROGRAM INFORMATION
*denotes required field

*Select Today's Date:

Select Date

Program Year:

NHI Program:

*First Choice:

*Second Choice:

Did you attend the YLC/Great Debate?:

If you were nominated by an NHI Alumnus, please add their information below.

NHI Alum FName:

NHI Alum LName:

NHI Alum Email:

NHI Alum Program & Year:

STUDENT INFORMATION

*Gender:

*First Name:

Middle Initial:

*Last Name:

Mother's Maiden Name:

Optional

*Address:

Address II (Colonia):

*City:

*State:

Use state abbreviations (e.g. TX)

*Zip Code:

*Country:

*Home Phone:

*Email:

Use best email to contact you

Mobile Phone:

*Can NHI send you text messages to your mobile (std rates apply)?:

*Date of Birth:

Social Security Number (Optional):

*Which of the following do you have?:

FacebookMySpaceBothNone

If MySpace, www.myspace.com/:

SCHOOL INFORMATION

*High School:

*Graduation Year:

PARENT/GUARDIAN INFORMATION

*Who is the primary contact to receive information?:

*Language Preferece:

*How would you like to receive information from NHI?:

*Parent/Guardian I:

Employer:

Title:

Work Number:

*Email:

Mobile Number:

Can NHI send you text messages to your mobile (std rates apply)?:

Parent/Guardian II:

Employer:

Title:

Work Number:

Email:

Mobile Number:

Can NHI send you text message to your mobile regarding your child's account (std rates apply)?:

NHI Terms & Conditions:

I understand by clicking "SUBMIT & CONTINUE," I am providing the National Hispanic Institute an ELECTRONIC SIGNATURE. This confims the following:

I am submitting this application for consideration of admission for NHI's leadership programs;
The information I provided in this application is accurate and true to the best of my knowledge;
Submitting my application does not guarantee me admission to NHI's leadership programs;
I also understand that I will need to submit additional items to NHI to complete the admissions process. Specifically, I will submit my first six week report card to NHI to verify that I meet the required 3.2/88 grade point average; and
I understand that my application fee of $20 is non-refundable.