Name ______________________________________________________________

Address ____________________________________________________________

___________________________________________________________________

Phone Number _______________________________________________________

Parent / Guardian(s) Name ______________________________________________

Are you a citizen of the United States of America? ____________________________

High School _________________________________________________________

Extra Curricular Activities _______________________________________________

__________________________________________________________________

Community Involvement / Employment _____________________________________
__________________________________________________________________

__________________________________________________________________

Post Secondary Institution to which
you have been accepted _______________________________________________

Location ___________________________________________________________

Major ______________________________________________________________

Career Goal _________________________________________________________

Attachments:
1) Transcript, which includes GPA, ACT or SAT scores if applicable
2) Resume
3) Essay