| Contact Information:
An * indicates a required field. |
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| Name | |
| First Middle | Last |
| Phone | |
Cell Phone | |
| (include area code and no dashes) | (include area code and no dashes) |
| Email Address | |
Best Way to Contact You |
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| Street Address | |
| City, State | |
Zip Code | |
| Age | |
Birthdate | (enter date as mm/dd/yyyy) |
Gender |
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| Ethnicity |
| Other Ethnicity |
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| Who do you live with? | |
| Number of persons in family(including parents and self) | |
| Parents are |
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If Parent(s) are deceased, please indicate |
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| Father's Contact Information |
| Name | |
Age | |
| Street Address | (enter only if different from applicant's) |
| City, State | |
Zip Code | |
| Phone | |
Occupation | |
| Employer | |
Work Phone | |
| If Applicable, Stepfather Contact Information |
| Name | |
Address | |
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| Mother's Contact Information |
| Name | |
Age | |
| Street Address | (enter only if different from applicant's) |
| City, State | |
Zip Code | |
| Phone | |
Occupation | |
| Employer | |
Work Phone | |
| If Applicable, Stepmother Contact Information |
| Name | |
Address | |
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| Financing for College |
| Who is responsible for financing your college education? | |
| If you have a savings account for college expenses, please indicate the amount | |
| Number of family members who will be in college same time as you | |
| Intended Career | |
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| Education Information |
| High School | |
Grade Level (Number) | |
| Graduation Year | (4 digit year . Example: 2010) |
Grade | (Grade Average. For example 96, 97.4, etc) |
| Counselor Name | |
| Courses of Interest | |
| Colleges interested | |
| Proposed College Major | |
| Scholarships awarded | |
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| Current Year Course Schedule |
| Does the school have block scheduling (A/B days)? |
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| Anticiapted Senior Year Course Schedule |
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| School Activities: Indicate if you are participating in any of the following programs or school activities |
| Programs |
University Outreach
Upward Bound
TAME/SAME
PREPOutreach
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| Hobbies |
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| School Actvities |
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| Job: After-School or Weekend Job |
| Do you have after school or weekend job? |
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| If so, how many hours? | |
| Position | |
| Responsibilities | |
| Length of time Employed | |
| Supervisor | |
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| References: List three non-family member references |
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