1. Last Name    

    First Name     

    Middle Name 

2. Street Address

    City   State

    Zip Code

    Your Phone Number

    Your Email Address 

3.  Social Security Number (If you have it)  

4.  Personal Data

    Your Date of Birth (MM/DD/YYYY)

   Male Female

   Your Parents

   Father's Name 

   Mother's Name

   Work phone No. for father  

   Work phone No. for mother

   Occupation for father       

   Occupation for mother    

5. Education Background

    Date of Last Educational Evaluation

    Name of High School

   Graduation Date

   Grade point average from high school

   If you are planning to enter to college, what is your proposed major

   Have you been diagnosed as learning disabled/ADHD?

 Yes No

   If yes, by whom? Give name and address

   Name Address

   Were you in a Learning Disabilities class in high school?

Yes No

   If so, please state how much time and in what areas you received help:

   How much time

   In what areas   

   Do you have problems with the following? Please check all that apply

Note-taking                                                Reading

Study Skills                                       Written language

Test-taking strategies                             Mathematics

Organizational skills                                 ADHD/ADHD (attention span)

Difficulty with reading                              Other

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After completing the application please go to the application checklist to find out what is needed to complete your application.