NAME_____________________________________________________PERIOD______________________
ADDRESS________________________________ ________CITY________________ZIP CODE_________
HOME PHONE______________________________________CELL PHONE________________________
SCHOOL EMAIL__________________________________________________________________________
FATHER’S NAME__________________________________PROFESSION__________________________
EMPLOYED AT____________________________________WORK PHONE________________________
FATHER’S EMAIL__________________________________CELL PHONE_________________________
MOTHER’S NAME__________________________________PROFESSION_________________________
EMPLOYED AT____________________________________WORK PHONE________________________
MOTHER’S EMAIL_________________________________CELL PHONE_________________________
STUDENT LIVES WITH: BOTH PARENTS
Period Subject – 1st Semester with Teacher and
Room Number
0
1
2
3
4
5
6
7
8
FATHER
MOTHER
OTHER________________
Subject – 2nd Semester (with Teacher and Room
Number
LIST YOUR TOP 5 COLLEGES THAT YOU ARE INTERESTED IN/APPLYING TO IN PRIORITY
and your major area of study at each (if the same at all, put your major by your first priority)
1
2
3
4
5
DESCRIBE YOUR POST-UNDERGRADUATE PLANS (DEGREES and CAREER INTERESTS)
LIST EXTRACURRICULAR (academic, athletic, club, drama, music, etc.) ACTIVITIES and HONOR
SOCIETIES (including offices held) IN WHICH YOU ARE A MEMBER
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