Admissions Application
DATE: _______________
Female
Year of Interest _____________
Tem: Fall
Male
Spring
Name: ___________________________________________________________________________________________________________________________
First
Middle
Last
Nickname/Preferred Name: _________________________
Birth Date: ___________________________
Street/PO Box: ____________________________________________________________________________
City, State, Zip: ___________________________________________________________________________
Home Phone Number: (_____)___________________
Cell Phone Number: (_____)__________________
E-Mail: __________________________________________________________________________________
High School you will graduate from/graduated from: ___________________________________________
City and State of High School: _______________________________________________________________
Graduation Year: ________
Guidance Counselor: ____________________________________________
Transfer Student: Yes
No
For transfer students, college currently attending: ______________________________________________
At this time I am interested in studying (if known): ______________________________________________
Please list any activities in which you are involved (athletics, clubs, youth groups, volunteer work, etc.):
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Please tell us about any awards you have received (academic, athletic, clubs, etc.):
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
SAT CR ________ M ________
Class Rank ________/________
ACT ________
Grade Point Average ________
Have you ever been dismissed for academic reasons?
Yes____ No____
Have you ever been dismissed for disciplinary reasons? Yes____ No____
Are you a US citizen or permanent resident?
Yes____ No____
If not, of what country/countries are you a citizen? ______________________________________________
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•
•
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Social Security Number (optional)______________________________________
If you are a US permanent resident or green card holder, please give us your alien registration
number___________________________________
If you are not a US citizen, of what country are you a citizen?_________________________________
If you are a dual citizen of the US and another country, please tell us which other
county_______________________________________
(Required to ask by the U.S. Government for reporting purposes but your answer is optional)
Ethnicity:
_____Hispanic/Latino
_____ Not Hispanic/Latino
Race (select one or more):
_____American Indian or Alaskan Native _____Asian _____Black or African American
_____ Native Hawaiian or Other Pacific Islander _____White
Dependent students must provide parent/guardian’s name and address below:
Name_________________________________________________________________________
Address (if different from yours)_________________________________________________________
____________________________________________________
City
State
Zip Code
Email Address ________________________________________
Telephone_(_____)________________
Cell Phone (___)___________________
My signature below indicates that all information is complete, factually correct and honestly represented. In
addition, it indicates that if accepted to Randolph College I will uphold the standards of the following Honor
Pledge:
I pledge absolute honesty in my academic work and in all personal relationships at Randolph College. I will
maintain the integrity of my word and I will respect the rights of others. Realizing that these standards are an
integral part of life at Randolph College, I assume my obligation to uphold this honor pledge. If at any time I fail to
live up to my obligation of this pledge, I will report myself to the Chair of the Judiciary Committee. I will also ask
others to report themselves for any infraction of this pledge.
Signature_________________________________________________
Submit Application
Date______________________