Student Registration Student Representative Information If you are a Representative assisting the Student, please complete this section. Who should Read Now contact?---RepresentativeStudent Choose one Representative Name Enter your full name Email Enter a valid email Mobile Phone Enter a valid phone number Home Phone Enter a valid phone number When is the best day and time to reach you?---WeekdayWeekend Choose one ---MorningAfternoonEvening Choose one Prospective Student Application * Please complete the required fields with the asterisk * Student Name Enter your full name Gender Address Line 1 Enter your street address Address Line 2 * City Enter your city of residence * State---AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKentuckyKansasLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyoming Choose one * Zip Code Enter your zipcode of residence * Mobile Phone Enter a valid phone number Home Phone Enter a valid phone number * Email Enter a valid email How did you learn about Read Now ?---GoogleSocial media (Instagram, Facebook, Youtube)YelpProfessional (LinkedIn)RadioReferralOther Choose one If there is anything else you would like to add, you may do so at this time: * Read Now requires all Students to be age 18 or older. Are you 18 years of age or above?---YesNo Choose one * I agree to be contacted by Read Now to determine eligibility to become a Read Now Student.---AgreeDisagree Choose one * When is the best day and time to reach you?---WeekdayWeekend Choose one ---MorningAfternoonEvening Choose one * Signature Typing your name is the same as electronically signing * Date (MM/DD/YY) Enter a valid date Please leave this field empty. Thank you for taking the first step to becoming a Read Now student!
