Name *

First Name

Last Name

Birthday

MM

DD

YYYY

Phone Number

(###)

###

####

Indicate which schools/organizations in which you were primarily affiliated. *

Loyola University (LASO)

Mississippi State University (MSU VSA)

University of Mississippi (Ole VASA)

Tulane University (TUVA)

University of Alabama (USA VSA)

University of New Orleans (UNO-VASA)

University of Southern Mississippi (USM VSA)

Louisiana State University (VSA-LSU)

University of Louisiana at Lafayette (VSOUL)

Xavier University of Louisiana (XULAVA)

UVSA Gulf Coast

Have you read and do you agree to the above terms and conditions? *

Yes, I have read and agreed to the above terms and conditions.