E-mail Address:
First Name:
Middle Name:
Last Name:
Date of Birth (mm/dd/yy):
Student ID:
For Semester:
Address 1:
Address 2:
City:
State/Province:
Country:
Zip Code:
Phone:
Colleges or Universities:
Dates Attended:
Degree or Diploma:
Scholastic Average:
Scholastic Scale:
Date (month/year):
School and Department:
Yes: No:
If yes, give his/her name::
When do you expect to receive your undergraduate degree? (month/year):
If yes, what degree?
If yes, please describe.: Previous Group Living Experience
Name of Housing:
Type of Housing:
Dates:
List any group living offices you held, honors received, or activities in which you participated:
Please list your undergraduate extracurricular activities including offices held, honors received, etc.:
Describe the nature and dates of current or previous employment, or military service experience. Please include any counseling type of position or group supervisory experience.:
How do you spend your leisure time? (hobbies, special skills, etc.):
