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Collegiate Concierge and Coaching Intake Form - Student
The following information is collected for consulting and will be held in private by Collegiate Concierge & Coaching. Collegiate Concierge & Coaching has extensive experience in higher education ranging from prospective students still in high school to graduate and professional school applicants and is willing to provide services to students and their families based on this background. Before any services are agreed upon or commitments made by either party the following information must be provided. Following completion and receipt of information Collegiate Concierge & Coaching, LLC will follow up with the student and their family to discuss potential services and next steps.
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* Indicates required question
First and Last Name
*
Your answer
Birth Date
*
dd/mm/yyyy
Your answer
Phone number
*
Your answer
Email address
*
Your answer
Address
*
Your answer
City, State, and Zip Code
*
Your answer
High School
*
Your answer
Current Grade
*
9th
10th
11th
12th
HS graduate/no college
Required
Current GPA
*
Your answer
Expected High School Graduation Date (i.e.June 2016)
*
Your answer
Are you a student athlete?
*
Choose
Yes, and I
Yes, but I do not plan to play at the college level or yes, but I only plan to play for fun at the college level
No
List your current class schedule
*
Your answer
List previous courses completed including grades
*
(Example – Freshman English (A), Spanish I (B), etc.)
Your answer
List the classes you expect to take moving forward including an indication of any which may be AP courses or taken at local Colleges/Universities
*
Your answer
List all activities that you are invovled in with the high school (sports, clubs, etc.) and include your positions (captain, member, officer, etc.
*
Your answer
List all extracurricular activites that you are involved with outside your high school (church, clubs, sports, etc.) and include your positions (captain, member, officer, etc.).
*
Your answer
List all volunteer or other activities including employment that you are involved with and include your positions.
*
Your answer
Share with us, in your own words what your goals are for a future career:
*
Your answer
Share with us, in your own words, what you plan on studying to help you achieve this goal (think college major):
*
Your answer
Share with us where you would like to go to College and include back up plan Colleges/Universities. Please list the schools in your order of preference beginning with your top pick:
*
Your answer
Share with us how you chose the schools you are interested in attending and how you determined your order of preference:
*
Your answer
Have you ever had an Individual Education Plan (IEP) or 504 Plan while in High School?
*
Choose
YES
NO
Do you work with any tutors? If yes, please share with us who you are working with.
Your answer
How did you hear about Collegiate Concierge and Coaching?
*
Friend/Family
Website
Community Event
Other _____________________
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