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First Name: *

Last Name: *

Preferred Name (e.g. Johnathan = John):

Age:

Email: *

Phone: *

School: *

Undergraduate/Graduate Student:

Undergraduate

Graduate Student

Expected Graduation Date (Month/Year):

GPA:

Date of Incident: *

Location of Incident (e.g., in your dorm, off campus, etc.): *

What is your preferred way to be contacted?:

Email

Phone

Please describe the incident. Use as much detail as you feel comfortable supplying:

Have you been in trouble at this school before? If your answer is "yes", what happened?:

Have you met with any officials from the University? If so, who are they and what are their positions with the university?:

Has there been a hearing date set? If so, when?:

Have you been charged with any specific violations? If so, what are they?:

Are there any deadlines you know of at this time? If so, what are they?:

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