General Information

*	Check the term you want to begin
	Term I (Fall)	Term II (Winter)	Term III (Spring)	Summer
*	Status (Check all the items that will pertain to you)
	Full-time	Daytime
	Part-time	Evening/Weekend Program

Personal Information

*

Last Name

* First Name

Middle Name

*	Home Address

*	City		* State	* Zip
*	Home Phone		Cell Phone
*	Social Security
*	Date of Birth	City of Birth		State of Birth
	Country of Birth		Country of Citizenship
	If you are a permanent resident alien (PRA), list your PRA Number
*	Marital Status		Maiden or Former Name
*	Gender  Male  Female
	E-mail Address

	Ethnicity & Race
	Do you identify yourself as Hispanic/Latino?: Yes   No
	Select one or more of the following racial categories:
	American Indian or Alaska Native		Asian	Black or African American
	Native Hawaiian or Other Pacific Islander			White
	Religious Affiliation (optional)
	Military Experience Veteran  Non-Veteran  Now in Service  Military Training Location Other
	Employer		Office Phone ()
	Can you conveniently receive calls at work?  Yes No
	Have you ever been on disciplinary probation by a college or university? Yes No
	Have you ever been suspended or dismissed from a college or university for disciplinary reasons? Yes No

Education

High School

Address

	City		State	Zip
	Phone Number		Graduation Year
	High School Guidance Counselor
	GED Yes No	If Yes, date received

	Briar Cliff University requires the American College Test (ACT) or the College Board Assessment Tests (SAT)
	ACT Score	ACT Date	Cumulative GPA
	SAT Score	SAT Date
	Are you registered to take either test in the future?
	ACT   Date Scheduled
	SAT   Date Scheduled

	College and Other Schools (including military training)
	School	City		State	Years Attended
					to
					to
					to
					to
					to

	What motivated you to contact BCU?
	Word of Mouth  Direct Mail  Internet/Website  TV Ad Radio Ad Newspaper Ad Other
	What most influenced you to apply at Briar Cliff?
	Do you plan to apply to other colleges? Yes No
	If so, please list others in order of preference
	Honors/Awards
	Briefly describe any scholastic distinctions or honors you have received in high school

Career Interest

*	Major field of academic interest
	Career Plans

Activities

	Please list church, community, and athletic activities
	Which activities and/or sports do you wish to participate in at Briar Cliff?

Financial Assistance / Scholarships

	Do you plan to seek financial assistance?	Yes No
	Do you plan to audition for theatre scholarships?	Yes No
	Do you plan to audition for music scholarships?	Yes  No
	Do you plan to submit an art portfolio?	Yes No
	Do you plan to try out for an athletic scholarship?	Yes No
	Does your employer offer tuition benefits?	Yes  No
	If yes, in what amount? $
	What are the conditions for receiving the benefits?

Family Information

	Father and/or Guardian
	Address

	City		State	Zip
	Place of Employment

	Mother and/or Guardian
	Address

	City		State	Zip
	Place of Employment
	With whom do you live? (check all that apply)
	Father    Mother    Stepfather   Stepmother   Other
	If other, Please state Name and Relationship
	Name		Relationship
	Did either of the people who raised you graduate from BCU? Yes No
	Did either of the people who raised you graduate from a four-year college? Yes No

	Please list the names, ages, year in school (if applicable) of all siblings
	Last Name	First Name	Age	Year in School

	Do you have siblings currently attending BCU? Yes No
	Relatives who attended or currently attend Briar Cliff University
	Last Name	First Name	Relationship	Year Attended

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