Admissions Form / part 1.Admissions Application

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1 Return all Items to: / N.W. 42 nd Ave. Miami Gardens, Florida (305) Admissions Form / part 1.Admissions Application Applicant Information (Please Print Clearly) Term /Year of Entrance Location Main Campus Off Campus Site Name (Last, First, Middle) Home Phone Application Status First Time Transfer Re-admit Other Gender* (optional) Age * (optional) BIRTHDATE (m/d/y) Marital Status* Ethnic Origin* (optional) Nation of Birth Nation of citizenship (if different than Birth) Scholastic Information High School Attended CEEB# CITY STATE ZIP High School Phone Date of Graduation (M/D/Y) Estimated Grade Point Average High School Equivalency (GED) Intended Major S.A.T. Verbal S.A.T. Quantitative A.C.T. Math A.C.T. English A.C.T. Reading Other Information Do You plan to live on campus? Yes No Do you plan to apply for financial Aid? Yes No Incase of an emergency, contact: Relationship to applicant Phone Transfer Students only (If you ve attended more than three schools, list additional information on reverse side) College/University Address City/State Year(s) Of Attendance Have you ever been placed on Academic or School Probation? Yes No If yes, explain briefly: Have you ever been convicted or found guilty of violation any federal, state or local law/ ordinance other than a traffic violation? Yes No If yes, explain briefly: How did you hear About? Radio TV Mailing School Counselor Newspaper/Magazine Other Referred to By: Address Phone I certify that the above information I have Signature provided is accurate * This information will not be used for discriminatory purposes. Date

2 Return Admission Forms / part 2 Official Transcript Release form All Items to: Prospective student: Please complete the required information below ands forward it to your high school or College. If you need additional Transcript Release forms, photocopy this one. Request is herby made for the release of my official transcript and test scores in order to complete the admissions process at. School Information High School Name Student Information Applicant Name Permanent Address City State Zip BirthDate (M/D/Y) Date of last Attendance Student Signature

3 Admission Forms / part 3 Letter Of Recommendation Applicant Name (Last, First, Middle) Recommender Name (Last, First, Middle) Phone Relationship to the Applicant: Teacher Guidance Counselor Pastor Other Please indicate what you know about Applicant s background: His/her family circumstances, home environment, neighborhood and any other information relating to his/her background. Please sate Applicant s attitude toward education, his/her specific strengths, weakness, achievements and other relevant scholastic information. We are also interested in your assessment of the Applicant s level of motivation and capacity for hard work.

4 Admission Forms / part 4 Personal Statement Name (Last, First, Middle) Phone School Name On this page we would like you to tell us something about yourself. Without asking for an autobiography, we would like to learn a little more about the experiences and thoughts that have made you the person you are. Most of the contents of an admissions folder are either facts or judgments made by those who have known or worked with you. In addition, we found it helpful to read some of your own comments. We asked you to accept one condition as you write: do not consult with anyone in this preparation or show anyone your statement before mailing it to us. You may use written sources to check the correctness of your writing or you may refer to work you have read. Your signature at the end of this page will indicate that you wish us to accept the writing as your own. If you wish, you may use extra pages. Signature

5 Admission Forms / part 5 Medical Information Please Fill out Student Information section and forward to you physician Applicant Name(Last, First, Middle) Birth Date (M/D/Y) Phone In case of an Emergency, contact: Relationship to Applicant Phone Medical History List any Allergies or Drug Sensitivities List/Describe Any Hospitalizations and/or operations Is there any History of the following conditions in your family If so, indicate who. M=mother, F=Father, U=Uncle, A=Aunt, S=Sister, B=Brother, GM=Grandmother, GF= Grand father, C=Cousin Anemia Asthma Diabetes Eczema Epilepsy Hay fever Heart Disease High Bld. Prsr. Mental Illness Migraines Nerv. Disorder Tuberculosis Height Weight Eyes Left Right Ears Nose Mouth Throat Tonsils Neck Chest/Lungs Heart/Pulse Anemia Abdomen Spine/Back Diabetes Hypertension Extremities From a Physical and medical point of view, do you consider the applicant able to enroll in a collegiate program and to participate in sports and recreation? Yes No If no please explain: OB-GYN History Urinalysis Age of Menarche Date of I.M.P. Reaction SP. GR. ALB. Sugar Hematocrit HgB Number of Pregnancies Births Date of last Pap Smear (M/D/Y) Chest X-Ray Tine Test or Manoux Positive Negative Date Positive Negative Date Immunization Tetnaus / Date: Small Pox/Date: Polio/Date: MMR #1/Date: MMR #2/Date: Doctor s Doctor s Name (Please Print) Doctor s Signature Doctor s Phone

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