CAC Student Intake Form

College Admission Coach, LLC Student Intake Form
STUDENT INFORMATION
Full Legal Name*

First NameMiddle NameLast Name
Nickname
Date of Birth*

MonthDayYear
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Telephone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Email Address*
School Attending*
Current GPA*
Weighted or Unweighted*
School Location (City, State)*
Current Grade

9101112
Are you seriously considering a gap year before starting college?*

YesNo
Race/Ethnicity (Check All That Apply)

CaucasianBlackAsianHispanicNative AmericanOther
If Asian, what type?
What is your gender identity?
What are your preferred pronouns?

she, her, hershe, him, histhey, them theirsze, hirUse only my name please
Do you identify as LGBTQ+?

yesnono, but I am a strong allychoose not to answer
FAMILY INFORMATION
Parent 1 Full Name*

First NameLast Name
Parent 2 Full Name

First NameLast Name
Sibling 1 Name

First NameLast Name
Sibling 1 Age
Sibling 1 School/College Attending (or Attended)
Sibling 2 Name

First NameLast Name
Sibling 2 Age
Sibling 2 School/College Attending (r Attended)
Sibling 3 Name

First NameLast Name
Sibling 3 Age
Sibling 3 School/College Attending (or Attended)
Sibling 4 Name

First NameLast Name
Sibling 4 Age
Sibling 4 School/College Attending (or Attended)
STUDENT PREFERENCES

What type of college do you see yourself attending? Please review the following and consideryour current priorities before ranking your choices. You may wish to discuss your answers withyour parents.

Geographic Location. Please Rank Choices in order of Importance (1 is most important)

	Ranking
Doesn't Matter
Northeast
Mid-Atlantic
South
Midwest
Mountains/Southwest
West Coast

Setting. Rank in order of Importance (1 is most important)

	Ranking
Doesn't Matter
Rural
Suburban
Urban

Size of University. Rank in order of importance. (1 is most important)

	Ranking
Doesn't Matter
Small(under 3,500 students)
Medium(3,500-10,000)
Large(10,000-20,000)
Very Large(20,000+)

Type of Institution. Rank in order of importance. (1 is most important)

	Ranking
Doesn't Matter
Coeducational
Single-sex

Atmosphere (Select All That Apply)*

Doesn't MatterConservativeMiddle-of-the-roadLiberalAlternative
What other characteristics are you looking for in your college (i.e. friendly, competitive, great football team to cheer for)?
What school characteristics would you like to avoid?
How important a consideration is institutional prestige?
How intensive an academic workload do you want?
Possible majors being considered:
Other academic interests:
Are there any colleges in which you are currently particularly interested? List them and explain why?
Have you ruled out any colleges? List them and explain why?
Will you need financial aid?*

YesNo
Do you want a part-time job?*

YesNo
Please list the courses you are currently taking and your approximate grades.
Please Attach a copy of your current transcript or submit it separately to Jodi.

Upload a File

Cancelof

SAT/PSAT Tests Taken to Date and Score

	DATE	Reading	Mathematics	Writing	Essay
PSAT
PSAT
SAT
SAT

SAT Subject Tests (list subject, date test was taken, and score):

	Subject	Date	Score
-
-
-
-

ACT/PLAN Tests taken to date and scores:

	DATE	Comp	English	Reading	Math	Science	Writing (Subscore)
PLAN
PLAN
ACT
ACT

AP (list subject, date test was taken, and score):

	Course	Date	Score
-
-
-
-
-
-
-
-

How do you assess yourself as a student? What do you consider your academic strengths and weaknesses? Do you think your transcript and teacher/counselor reports accurately reflect your academic abilities?
EXTRA-CURRICULAR ACTIVITIES

Please list your most important extra-curricular pursuits. Specify years of involvement and positions of leadership or responsibility, and rank them in importance to you.

School Activities and Sports

	Activity/Sport	Freshman	Sophomore	Junior	Senior	Leadership Position/Responsibilities
-
-
-
-
-
-

Outside Activities and Sports

	Activity/Sport	Freshman	Sophomore	Junior	Senior	Leadership Position/Responsibilities
-
-
-
-
-
-

Work/Volunteer/Summer Activities

	Activity/Sport	Freshman	Sophomore	Junior	Senior	Leadership Position/Responsibilities
-
-
-
-
-
-

Other Hobbies and Interests

	Activity/Sport	Freshman	Sophomore	Junior	Senior	Leadership Position/Responsibilities
-
-
-
-
-
-

Should be Empty:

College Admission Coach, LLC Student Intake Form

STUDENT INFORMATION

FAMILY INFORMATION

STUDENT PREFERENCES

EXTRA-CURRICULAR ACTIVITIES