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Student Application

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Personal Data
First Name:	Last Name:

Middle Name:	E-mail Address:

Mailing Address
Street/PO Box:	City:

State:	Zip Code:

Country:	County:

Phone:	Fax:

Mailing Address and Telephone valid
from	to
Home Address (complete only if different from above)
Street/PO Box:	City:

State:	Zip Code:

Country:	County:

Phone:	Fax:

Home Address and Telephone valid
from	to
Date of Birth: ( month , day , year)	Gender:

Is English your primary language?	If not, what is your primary language?

Citizen of the United States:

If not, are you legally a permanent resident?	Alien Reg. #

If not, what is your country of birth?	Citizenship

Optional Personal Information
The following request regarding race, national origin, or ethnicity of applicants has been recommended by the U.S. Department of Education, Office for Civil Rights. Please check appropriate category.
Ethnicity:	Birthplace: (City, State, Country)

Major(s) and Special Advising
My top two choices of majors are:
First: Second:
Optional: I am also interested in the following Special Advising Programs (you must also specify your first and second choice of majors above.
Pre-Med: Pre-Physical Therapy: Pre-Dentistry: Pre-Veterinary: Pre-Law:

Educational Data
Name of Secondary/High School:	Street/PO Box:

City:	State:

Zip Code:	County:

Country:

Full name of Secondary School Counselor or College Advisor:	Counselor E-mail Address:

Counselor Telephone Number:	Counselor Fax Number:

Graduation Year	At the end of this academic year you will have completed which level of secondary school?

List all high school science and mathematics courses you have completed:

What subjects are you registered for this year? List each course on a separate line, indicating honors, advanced placement, or accelerated courses.
First Semester:
Second Semester:

BIOGRAPHICAL INFORMATION
	Father	Mother	Guardian	Spouse
Full Name: (father , mother , guardian , spouse )
Occupation: (father , mother, guardian , spouse)
Employer: (father , mother, guardian , spouse )
College attended: (father , mother , guardian , spouse )
Degrees(s) and Dates: (father , mother , guardian , spouse )
If parents are divorced or separated, the primary custodial parent is:
Name:		Street Address:
City:		State:
Zip:		County

1. Clarkson Affiliation (School or University)
Name	Class of

Address	City

State	Zip

Clarkson	Relationship to You
Student Alum Staff Faculty
2. Clarkson Affiliation (School or University)
Name	Class of

Address	City

State	Zip

Clarkson	Relationship to You
Student Alum Staff Faculty

Please indicate any Clarkson campus programs in which you have been involved, including dates attended. (i.e. Horizons, Project Challenge, Sports camps, Young Scholars, etc.).

Please list your extracurricular activities in order of their importance (sports, service projects, clubs, special interests, etc) You may submit a resume for this section if you prefer.

Briefly describe any academic honors you have received or leadership positions you have held:

Essay

Along with this application, please submit an essay of 150-300 words, in the form of a personal statement. The personal statement should provide the Admissions Committee with a sense of you as an individual so that we may have the opportunity to get to know you better through your writing. You may describe a special interest, experience or achievement that is important and meaningful to you.

Interview

An on-campus interview is encouraged as part of the admission procedure. Prospective students are asked to meet with a staff member to discuss the School's programs and how they may be individualized to meet the student's needs. Please call The Clarkson School office at 800-574-4425 to make arrangements for a campus visit. Telephone and off-campus interviews (in some geographic areas) may also be arranged.

I have already completed my interview

Date: (month , day , year )

Where:

Interviewer:

I hereby apply for admission to The Clarkson School. If admitted I agree to observe the regulations of the School. My parent or guardian has approved this application.

The $50.00 application fee will follow the application.

I have already had an interview, therefore, my application fee is waived.

I am requesting a fee waiver due to financial hardship (see your Guidance Counselor for this form, send to The Clarkson School).

I am resubmitting corrections to an application submitted earlier.

IT IS IMPORTANT TO NOTE: Due to security reasons we do not ask for your social security number on our on-line application. If you choose to utilize the on-line application, please call The Clarkson School Office at: 315-268-4425 or 1-800-574-4425 to provide us with your social security number. It is necessary for us to have students’ social security numbers on file when preparing accepted students’ financial aid packages.

EQUAL OPPORTUNITY POLICY: Clarkson University prohibits discrimination in all aspects of its operation. Clarkson offers admission to students without regard to handicap, race, color, sex, sexual orientation, national and ethnic origin, creed and religion. All students admitted to Clarkson have nondiscriminatory access to the University's available financial assistance, facilities, activities, and various programs.