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November 2024 Eagle Madness Preview Day
Bio/Demo Information
First Name
Last Name
Email Address
Cell Phone
Date of Birth
Home Phone
Check if address is outside of U.S. or Canada
Address Line1
Address Line2
Foreign Address Line
City
Postal Code
State/Province
Alabama
Alaska
Alberta
American Samoa
Arizona
Arkansas
British Columbia
California
Canal Zone
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba
Marshall Islands
Maryland
Massachusetts
Michigan
Military Americas
Military Europe
Military Pacific
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick
New Hampshire
New Jersey
New Mexico
New York
Newfoundland and Labrador
No Response
North Carolina
North Dakota
Northern Mariana Islands
Northwest Territories
Nova Scotia
Nunavut
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Prince Edward Island
Puerto Rico
Quebec
Republic of Palau
Rhode Island
Saskatchewan
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Yukon
Country
United States
Canada
Afghanistan
Aland Islands
Albania
Algeria
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic of the
Cook Islands
Costa Rica
Cote dIvoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic Peoples Republic Of
Korea, Republic Of
Kosovo
Kuwait
Kyrgyzstan
Lao Peoples Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, The Former Yugoslav Republic Of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Moldova, Republic Of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French Part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and South Sandwich Islands
South Sudan
Spain
Sri Lanka
Stateless
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province Of China
Tajikistan
Tanzania, United Republic Of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States Minor Outlying Islands
Unknown
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Gender
Female
Male
Nonbinary
-I Choose Not to Respond
Add another gender
Another, not listed
How would you identify yourself?
Describe your current status
Returning Life University Student
High School Freshman - Sophomore
High School Junior - Senior
Undergraduate College Student
Transfer student from an Undergraduate Institution
Graduate Student
Transfer student from another Chiropractic College
None of the above
Which Academic Level are you interested in?
Undergraduate
Graduate
Eagle Madness Specifics
Have you previously attended an Eagle Madness at Life University?
Yes
No
If yes, when?
How did you learn about Eagle Madness?
Advisor
Radio Advertisement
Friend of LIFE
Email Blast
Print Media
High School
LIFE U Faculty
LIFE U Staff Member
LIFEforce Tribe Member
Current Student
HOSA
Impact Tour
Name of referral
Please enter your referring party as FirstName LastName. If more than one person encouraged you to apply to LIFE, please enter their name(s) separated by a comma (,).
Is it OK for us to inform your Referral source of your registration?
Yes
No
What year will you graduate?
Do you have any dietary needs or restrictions?
Yes
No
Do you require special assistance?
Yes
No
Dietary needs or restrictions:
Will you attend the Welcome Reception?
Yes
No
Assistance specification(s):
How will you be traveling?
Plane
Drive
Train
Is your travel time more than 2 hours?
Yes
No
Do you require hotel accommodations?
Yes
No
Do you consent to photo & video during event?
Yes
No
How many guests will you bring?
0
1
2
How did you hear about Eagle Madness?
Did a LIFE U Recruiter assist in helping/referring you to this event?
Yes
No
Which Recruiter?
Andrea Bridges
Angela Skjeie
Ashleigh Guice
Ashley Farley
Asia Ore
Austin Lawrence
Brandon Anderson
Brian Gipson
Brittany Glover
Candace Trent
Carmina Bioc
Charmaine Townsend
Cheyenne Selden
Chris LeSage
Christy Shepherd
CRM Admin
Cynia Cadett
Danielle Albright
Erin Brick
Hurley Reed
Jennifer Steinbeck
Jerome Stockwell
Johkida Jackson
Julissa Norat
Keith Jordan
Krystal Burnett
LaChrista Nelson
Lia Brown
LIFE_Crm Admissions
Lipni Aspeitia
Magalie Remy
Magi Rodgers
Marian Morales
Matthew Shaul
Monika Autrey
Neil Belcher
Nicole Lee
Nigar Gafarzada
Rachel Hill
Rachel Reeves
SaQuinn Barnes
Sawanda Spinks
Scott Schappert
Sean Subulade
Shemika Withers
Shivakumar Bagalkot
SparkPost EmailService
Stella Broni
Stephanie Rainey
svc_api_life PowerBI Connection
Tatum Johnson
Taylor Stevens
Temur Saydulloev
Wessly Soronellas
Zain Zaidi
Club Activity
What Club are/were you most active in at your current/former institution?
None
Biology
Chiropractic
HOSA
Kinesiology
Pre-Med
Other
Club Specifics
Please list the institution and club name.
Are you an Academic Advisor
Yes
No
Which Institution?
Organization Name (full or partial)
In order to search by name, enter at least 3 characters of the name.
Country
United States
Canada
Afghanistan
Aland Islands
Albania
Algeria
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic of the
Cook Islands
Costa Rica
Cote dIvoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic Peoples Republic Of
Korea, Republic Of
Kosovo
Kuwait
Kyrgyzstan
Lao Peoples Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, The Former Yugoslav Republic Of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Moldova, Republic Of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French Part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and South Sandwich Islands
South Sudan
Spain
Sri Lanka
Stateless
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province Of China
Tajikistan
Tanzania, United Republic Of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States Minor Outlying Islands
Unknown
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
State/Province
Unlisted Institution Information
If you cannot locate your institution on the list above, please list the name, address, and contact information for the institution in the space below.
Academic Interests
Anticipated Academic Level
Doctor of Chiropractic
Undergraduate
Graduate
Non Matriculated
Post Baccalaureate
Anticipated Academic Program
Associate Degree in Health and Wellness
Bachelor of Arts in Environment and Sustainability
Bachelor of Science in Anatomy & Physiology
Bachelor of Science in Biology
Bachelor of Science in Biopsychology
Bachelor of Science in Computer Information System Technology
Bachelor of Science in Exercise Science
Bachelor of Science in Health Coaching
Bachelor of Science in Interdisciplinary Studies (formerly General Studies)
Bachelor of Science in Nutrition
Bachelor of Science in Psychology
Bachelor's in Business Administration
Doctor of Chiropractic
Master of Science in Positive Psychology
Master of Science in Sport Health Science
Nonmatriculated / Non-Degree Seeking
Pre-DC
Location
Atlanta
Online (Distance Education)
Anticipated Entry Quarter
Fall 2024 (Oct)
Winter 2025 (Jan)
Spring 2025 (April)
Summer 2025 (July)
Fall 2025 (Oct)
Winter 2026 (Jan)
Future Anticipated Start Year
Future Anticipated Term
Winter (Jan)
Spring (April)
Summer (July)
Fall (Oct)
Have you connected with a Recruiter?
No
Yes
Yes, but I don't remember their name
Which Recruiter?
Andrea Bridges
Angela Skjeie
Ashleigh Guice
Ashley Farley
Asia Ore
Austin Lawrence
Brandon Anderson
Brian Gipson
Brittany Glover
Candace Trent
Carmina Bioc
Charmaine Townsend
Cheyenne Selden
Chris LeSage
Christy Shepherd
CRM Admin
Cynia Cadett
Danielle Albright
Erin Brick
Hurley Reed
Jennifer Steinbeck
Jerome Stockwell
Johkida Jackson
Julissa Norat
Keith Jordan
Krystal Burnett
LaChrista Nelson
Lia Brown
LIFE_Crm Admissions
Lipni Aspeitia
Magalie Remy
Magi Rodgers
Marian Morales
Matthew Shaul
Monika Autrey
Neil Belcher
Nicole Lee
Nigar Gafarzada
Rachel Hill
Rachel Reeves
SaQuinn Barnes
Sawanda Spinks
Scott Schappert
Sean Subulade
Shemika Withers
Shivakumar Bagalkot
SparkPost EmailService
Stella Broni
Stephanie Rainey
svc_api_life PowerBI Connection
Tatum Johnson
Taylor Stevens
Temur Saydulloev
Wessly Soronellas
Zain Zaidi
How did you learn about LIFE U?
HS/College
Recruiter
Organization/Association
Social Media
Other
Which Recruiter?
Andrea Bridges
Angela Skjeie
Ashleigh Guice
Ashley Farley
Asia Ore
Austin Lawrence
Brandon Anderson
Brian Gipson
Brittany Glover
Candace Trent
Carmina Bioc
Charmaine Townsend
Cheyenne Selden
Chris LeSage
Christy Shepherd
CRM Admin
Cynia Cadett
Danielle Albright
Erin Brick
Hurley Reed
Jennifer Steinbeck
Jerome Stockwell
Johkida Jackson
Julissa Norat
Keith Jordan
Krystal Burnett
LaChrista Nelson
Lia Brown
LIFE_Crm Admissions
Lipni Aspeitia
Magalie Remy
Magi Rodgers
Marian Morales
Matthew Shaul
Monika Autrey
Neil Belcher
Nicole Lee
Nigar Gafarzada
Rachel Hill
Rachel Reeves
SaQuinn Barnes
Sawanda Spinks
Scott Schappert
Sean Subulade
Shemika Withers
Shivakumar Bagalkot
SparkPost EmailService
Stella Broni
Stephanie Rainey
svc_api_life PowerBI Connection
Tatum Johnson
Taylor Stevens
Temur Saydulloev
Wessly Soronellas
Zain Zaidi
High School or College Name
Organization Name (full or partial)
In order to search by name, enter at least 3 characters of the name.
Country
United States
Canada
Afghanistan
Aland Islands
Albania
Algeria
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic of the
Cook Islands
Costa Rica
Cote dIvoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic Peoples Republic Of
Korea, Republic Of
Kosovo
Kuwait
Kyrgyzstan
Lao Peoples Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, The Former Yugoslav Republic Of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Moldova, Republic Of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French Part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and South Sandwich Islands
South Sudan
Spain
Sri Lanka
Stateless
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province Of China
Tajikistan
Tanzania, United Republic Of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States Minor Outlying Islands
Unknown
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
State/Province
Which Organization or Association?
Alumni or Friend
LIFEforce Tribe Member
Georgia: Georgia 4 LIFE
Dynamic Essentials
Maximized Living
Ohio: Buckeyes for LIFE
New York: NYC LIFE
North Carolina: Tarheels for LIFE
Virginia: Unified with LIFE
Wisconsin: Badgers 4 LIFE
If other, how/where did you learn about Life University?
Name of referring party
Please enter your referring party as FirstName LastName. If more than one person encouraged you to apply to LIFE, please enter their name(s) separated by a comma (,).
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