General Information Statement

Parent: Complete this entire form once. If we are working with more than one of your children, return to this form after submitting once, and complete the first 2 sections again for each additional child.

Do not exit the program until you have completed the entire form, as your answers will not be saved until you click "Submit Answers" at the end of the form.

Student Information
Last Name First Name Middle Initial
Date of Birth / / Sex: M F
Resident of Current State Since / /		Current High School
Student’s Guidance Counselor		Year of High School Graduation
Student’s Intended College Major(s)		Student’s E-mail Address
Home Telephone		Student's Mobile Phone
Street Address
City State Zip

Take this opportunity to share perspectives about your child that are as meaningful possible. The more you share, the more effective we may be in our recommendations. This helps us understand how well your child may fit a particular college's profile. For this section we only require the comments from one parent. The textboxes below have unlimited space available for your comments.

Questions for the Parent(s)
1. What do you want most for your child?	2. What are your child’s best qualities?
3. What activity or experience is the single most significant in expressing those best qualities?	4. Please describe any special occurrences which might have affected your child’s school record.
5. Any additional comments you’d like to make

Information about the parent(s) and family

Note: Parents are defined as the adults with whom the student applicant currently lives. If parent with whom the student resides is remarried, complete this form for yourself and your current spouse.

Parent 1 Information
Full Name		Phone Number
Date of Birth	/ /	Age
Occupation/Employer / Years
Highest Grade Completed		Resident of Current State Since / /
Did you attend college?	Yes No	Where?
Major
Would you be interested in allowing a student to job shadow you to gain experience in your field? Yes No
Parent(s) E-mail Address		Your Accountant’s Name
Parent 2 Information
Full Name		Phone Number
Date of Birth	/ /	Age
Occupation/Employer / Years
Highest Grade Completed		Resident of Current State Since / /
Did you attend college?	Yes No	Where?
Major
Would you be interested in allowing a student to job shadow you to gain experience in your field? Yes No
Marital Status
Student's natural parents are:
If Divorced:
Date of Separation	/ /	Date of Divorce	/ /
NOTE: Please describe any agreement noted in your divorce decree with regards to payment of college costs. Don’t leave blank.

Please list ALL family/household members below, including the student applicant and parents:

Full Name	Age	Date of Birth	Current Grade	School Name
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Please list anyone you know who would like help with college planning. We will be happy to send them information or contact them. We greatly appreciate your referral.

Name	Address	Phone #

We often speak at fundraisers and meetings for civic and youth organizations. Do you know of any community organizations or groups that would like to have a speaker on college planning issues?

Name of Contact	Address	Phone #

Click only once, please.