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Harwell & Cook Orthodontics
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NAME
*
ADDRESS
*
ZIP
Phone
*
Email
*
AGE
DATE OF BIRTH
MM slash DD slash YYYY
SS#
US CITIZEN
YES
NO
Middle School Attended
Elementary School
RANK IN CLASS
Numeric Avg.
ACT Composite
SAT Combined
Parent/Guardian Name/Occupations/Places of Employment
Number of brothers/sisters
Ages
How many family members, including yourself, will be in college next year?
List most notable community activities & school-related extra-curricular activities during grades 9 – 12 and check the appropriate grade level(s)
ACTIVITIES
Grade level
9
10
11
12
Level of Involvement (i.e. officer, member, etc.)
ACTIVITIES
Grade level
9
10
11
12
Level of Involvement (i.e. officer, member, etc.)
ACTIVITIES
Grade level
9
10
11
12
Level of Involvement (i.e. officer, member, etc.)
ACTIVITIES
Grade level
9
10
11
12
Level of Involvement (i.e. officer, member, etc.)
List special recognition, awards and honors received during grades 9 – 12 and check the appropriate grade level(s).
SPECIAL RECOGNITION, AWARDS OR HONORS
Grade level
9
10
11
12
Group or Activity Sponsoring the recognition
SPECIAL RECOGNITION, AWARDS OR HONORS
Grade level
9
10
11
12
Group or Activity Sponsoring the recognition
SPECIAL RECOGNITION, AWARDS OR HONORS
Grade level
9
10
11
12
Group or Activity Sponsoring the recognition
SPECIAL RECOGNITION, AWARDS OR HONORS
Grade level
9
10
11
12
Group or Activity Sponsoring the recognition
List and describe any work experience during grades 9 – 12 and check the appropriate grade level(s).
PLACE OF EMPLOYMENT
Grade level
9
10
11
12
Job Description
Supervisor
PLACE OF EMPLOYMENT
Grade level
9
10
11
12
Job Description
Supervisor
PLACE OF EMPLOYMENT
Grade level
9
10
11
12
Job Description
Supervisor
PLACE OF EMPLOYMENT
Grade level
9
10
11
12
Job Description
Supervisor
What college do you plan to attend?
Estimate college expenses for freshman year
Student Photo
Max. file size: 8 MB.
Print Name
Student Transcript
Max. file size: 8 MB.
Graduating Year
Student’s Signature
Max. file size: 8 MB.
Date
MM slash DD slash YYYY
Essay #1
Accepted file types: doc, docx, pdf, txt, Max. file size: 8 MB.
Essay #2
Accepted file types: doc, docx, pdf, txt, Max. file size: 8 MB.
Parent’s Signature
Max. file size: 8 MB.
Date
MM slash DD slash YYYY
Print Name
