H&C College Prep Coaching Application Form

Participant's Name*

Participant's Email *

Participant's Street address*

Participant's Street address line 2

Participant's City*

State*

Participant's Phone number*

Zip code*

Birth Date

Gender*

FemaleMaleOther

Ethnic Background

BlackHispanicCaucasian/WhiteOther

High School Grade Level*

9th Grade10th Grade11th Grade12th Grade

List Advanced Placement (AP) Courses and check those courses you took the AP Exam

Did you take the following exams?

SATACT

Exam Score

Overall grade point average weighted

Overall grade point average unweighted

List High School Activities. Identify leadership roles.

Have you decided on a major?

YesNo

If yes, what do you plan to major in?

List Colleges/Universities or Community Colleges You Are interested in Attending

Participant E-Signature*

Participant's Parent or Guardian Name*

Parent or Guardian Email*

Parent or Guardian Street address*

Parent or Guardian St. address line 2

Parent or Guardian City*

State*

Zip code*

Parent or Guardian Phone number*

Parent or Guardian E-Signature*