Student and Family Information Form for College Counseling

To provide us with the basic information that we need to get things going, you can fill out and submit the form shown below, which sends the information to us via email, or you can open our PDF version of the form, print it out, fill it out, and mail it to the address listed on that form.

Student Information

Student Name:

Mailing Address:

Email:

Home Phone:

Cell Phone:

Date of Birth:

Country of Birth:

Citizenship:

Current School:

School Address:

School Phone:

Graduation Year:

School Counselor:

Previous Schools: List schools by name and include the enrollment dates and grades attended

Family Information

Father's Name:

Mailing Address:

Email:

Phone:

Cell Phone:

Country of Birth:

Occupation:

Employer:

High School:

College:

Grad. School:

Mother's Name:

Mailing Address:

Email:

Phone:

Cell Phone:

Country of Birth:

Occupation:

Employer:

High School:

College:

Grad. School: