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Student Information
Student Name
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Student Date of Birth
*
Address
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Tokelau
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Armed Forces (AA)
Armed Forces (AE)
Armed Forces (AP)
American Samoa
Guam
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Puerto Rico
US Minor Outlying Islands
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Zip code
Student Email Address
*
Student Cell Phone Number
*
Biological Gender
*
Male
Female
Age
*
Grade
*
School
*
Applicant lives with:
*
Father
Mother
Both Parents
Other
Check any that apply
Father deceased
Mother deceased
Parents divorced
Parents separated
Father remarried
Mother remarried
Are you a U.S. citizen?
*
Yes
No
Other
Other
In what sports and/or after school activities does the student participate?
*
What community groups and/or organizations does the student belong to?
*
1st Parent/Guardian Information
Name
*
Address (if different from above)
Country
United States (US)
United Kingdom (UK)
Canada
Australia
---
Afghanistan
Åland Islands
Albania
Algeria
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
American Samoa
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belau
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo (Brazzaville)
Congo (Kinshasa)
Cook Islands
Costa Rica
Croatia
Cuba
CuraÇao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Republic of Ireland
Isle of Man
Israel
Italy
Ivory Coast
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao S.A.R., China
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Norway
Oman
Pakistan
Palestinian Territory
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Qatar
Reunion
Romania
Russia
Rwanda
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Martin (Dutch part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
San Marino
São Tomé and Príncipe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia/Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
Uruguay
Uzbekistan
Vanuatu
Vatican
Venezuela
Vietnam
Wallis and Futuna
Western Sahara
Western Samoa
Yemen
Zambia
Zimbabwe
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces (AA)
Armed Forces (AE)
Armed Forces (AP)
American Samoa
Guam
Northern Mariana Islands
Puerto Rico
US Minor Outlying Islands
US Virgin Islands
Zip code
Phone
*
Email
*
Occupation
*
College (if any)
Graduate school (if any)
2nd Parent/Guardian Information
Name
Address (if different from above)
Country
United States (US)
United Kingdom (UK)
Canada
Australia
---
Afghanistan
Åland Islands
Albania
Algeria
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
American Samoa
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belau
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo (Brazzaville)
Congo (Kinshasa)
Cook Islands
Costa Rica
Croatia
Cuba
CuraÇao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Republic of Ireland
Isle of Man
Israel
Italy
Ivory Coast
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao S.A.R., China
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Norway
Oman
Pakistan
Palestinian Territory
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Qatar
Reunion
Romania
Russia
Rwanda
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Martin (Dutch part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
San Marino
São Tomé and Príncipe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia/Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
Uruguay
Uzbekistan
Vanuatu
Vatican
Venezuela
Vietnam
Wallis and Futuna
Western Sahara
Western Samoa
Yemen
Zambia
Zimbabwe
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces (AA)
Armed Forces (AE)
Armed Forces (AP)
American Samoa
Guam
Northern Mariana Islands
Puerto Rico
US Minor Outlying Islands
US Virgin Islands
Zip code
Phone
Email
Occupation
College (if any)
Graduate school (if any)
Sibling Information
Sibling Name
School
Birthdate
Graduation Year
Sibling Name
School
Birthdate
Graduation Year
Sibling Name
School
Birthdate
Graduation Year
Educational History
We also request that you please e-mail us a copy of the student’s transcript and standardized test scores.
Student Class Rank
Student GPA
Has the student taken the PSAT, ACT, or SAT?
*
Yes
No
Please list the scores for each section.
Has the student ever repeated a grade?
*
Yes
No
What grade was repeated and why?
Has the student ever been tested for a learning disability?
*
Yes
No
When and by whom was the student tested?
Was the student classified by the school?
*
Yes
No
When was the student classified?
What was the classification?
Is the student still classified?
Does the student have accommodations?
*
Yes
No
What accommodations?
Study Skills
On average, how much time does the student devote to homework each weekday night?
Do you have difficulty getting the student to complete homework?
*
Yes
No
Please explain difficulties you experience.
Has the student ever been tutored?
*
Yes
No
Which subjects and for how long?
Is the student currently being tutored?
*
Yes
No
How is the student responding? Do you expect to continue the tutoring?
Please evaluate the student in each of the following areas (1=deficient to 10=exceptional)
*
1
2
3
4
5
6
7
8
9
10
Reading
Study Skills
Time Management
Organization
Writing/English
Math
Confidence
Motivation
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