In association with
Student Information Form
Name Male Female
Address
City AL Alabama AK Alaska AZ Arizona AR Arkansas CA California CO Colorado CT Connecticut DE Delaware DC District of Columbia FL Florida GA Georgia HI Hawaii ID Idaho IL Illinois IN Indiana IA Iowa KS Kansas KY Kentucky LA Louisiana ME Maine MD Maryland MA Massachusetts MI Michigan MN Minnesota MS Mississippi MO Missouri MT Montana NE Nebraska NV Nevada NH New Hampshire NJ New Jersey NM New Mexico NY New York NC North Carolina ND North Dakota OH Ohio OK Oklahoma OR Oregon PA Pennsylvania RI Rhode Island SC South Carolina SD South Dakota TN Tennessee TX Texas UT Utah VT Vermont VA Virginia WA Washington WV West Virginia WI Wisconsin WY Wyoming Zip
Home Phone Cell Phone
Date of Birth Email
Present School Grade/Year
HS Counselor
FAMILY INFORMATION:
Father’s Name Home Phone
Occupation Employer
Work Phone Fax Number
College Attended Degree
Graduate studies Do you live with him? Yes No
Mother’s Name Home Phone
Graduate studies Do you live with her? Yes No
Names of Brothers and Sisters:
Name Age College (if any) Degree Occupation
REFERRAL/REASON:
Who referred you to College Counseling Service?
Reason for your visit:
SCHOOL INFORMATION:
Schools student has attended:
Name Grade(s) City, State Public Private
Special type of Curriculum–AP, IB, Special Education, ESL, Accelerated, etc.
Current Cumulative GPA: Weighted Unweighted
Class Rank: Weighted Unweighted
Test Scores:
PSAT: Date taken: CR M Wr Comp
SAT: Date taken: CR M Wr Comp
ACT: Date taken: CR M Wr Comp
SATII: Date taken: CR M Wr Comp
SPORTS:
EXTRACURRICULAR ACTIVITIES: (Attach resume if available)
VOLUNTEER WORK:
Please comment on anything else you would like us to know:
