Part One: Personal Information

First Name:

Last Name:

Preferred Name:

Class Year:

---Select a Year--- 2007 2008 2009 2010 2011

Please choose one:

Freshman Transfer Returning Student

Name of High School:

If a transfer, name of transfer
college/university:

Hometown City/State:

Major:

Double Major   Dual Major

Sequences:

Tentative career plans:

Have studied or plan to
study abroad:

Yes No

Study Abroad Location & Date:

Religious Affiliation:

---Select a Religious Affiliation--- Atheist Agnostic Baptist Buddhist Catholic Episcopalian Hindu Jewish Muslim Presbyterian Other Decline to Answer

Disabled:

Yes No

Ethnic Background:

---Select an Ethnic Background--- Asian African American Caucasian Latino Native American International Student Other Decline to Answer

Politically Active:

Yes No

What Political Affiliation:

---Select a Political Affiliation--- Democrat Green Party Independent Libertarian Republican Other None Decline to Answer

Part Two: Activities and Awards

Please indicate below your activities and awards.

• Incoming freshman should list high school activities and awards.


• Returning and transfer students should list college activities and awards.


• Format each entry like this:
            activity -- role -- calendar years -- class years
            Key Club -- Secretary -- '02-'03 -- Junior, Senior
            Civitas -- Coordinator -- '01-'02 -- Freshman, Sophomore
            Varsity track -- Member -- '04-'05 -- Senior
            NONE

Organizations
Examples: school newspaper or yearbook, academic organizations, social organizations, volunteer work, National Honor Society, etc.

Sports and Other Activities

Awards and Honors

Research and Internships

Hobbies

Part Three: Waiver, Agreement, and Submit

Please read the following information:

By submitting this information form, I give Claremont McKenna College permission to share this information with the benefactors of my scholarship fund(s). I also give permission to the Development Office to access my academic record for the purpose of assigning and reporting my scholarship.

I understand and agree to the above paragraph. I attest that all information submitted is accurate.