Name:
Last: First: Middle: Preferred:


Address: City: State: Zipcode:

Home Phone #: Date of Birth(MM/DD/YYYY): Soc. Security #:


Father/Guardian:

Work Phone #: Occupation:

Address: City: State: Zipcode:

Mother/Guardian:

Work Phone #: Occupation:

Address: City: State: Zipcode:

Brother's and Sister's (ages):


Academics:
High School:  College/Junior College:

School Address:

City: State: Zipcode:

HS GPA: College/JC GPA: HS Class Rank: Year of Graduation:

Intended Course of Study:

Interested in a degree in Engineering, Math, Computer Science or Economics(Y/N):

List all math courses taken beyond 9th Grade:

List all math courses in progress:

List all science courses taken beyond 9th Grade:

List all science courses in progress:

SAT Score: Date Taken:	Math:	Verbal:	Total:

ACT Score: Date Taken:	Math:	Verbal:	Sci/Reas:	Composite:

If you have not tested, when do you plan to?

Awards & Honors(Academic):

Guidance Counselor:	Phone #:


Athletic Information

Position:	Height:		Weight:

Basketball Coach:     Coach's School Phone Number:
	
Coach's Home Phone:	PPG:	RPG:	APG:	SPG:

Athletic Honors Received:

Top three colleges you would like to attend: