Personal Information
First:
Last:
Address:
City:
State:		Zip:
Date of Birth:		Height:
Home Phone:		Weight:
Cell Phone		When is a good time to call?
email:

Family Information
Parents Names
Occupations
Colleges
E-mail Address

Athletic Information
High School Coach's Name:
High School Coach's Phone Number:
High School Coach's E-mail:
Name of Club/YMCA Team:
Club/YMCA Coach's Name:
Club/YMCA Coach's Phone Number:
Club/YMCA Coach's E-mail:
Do you mind if we call your club coach?	Yes No
Would you like to hear from a Brandeis Swimmer?	Yes No
Would you like to hear from an Alumni?	Yes No
PLEASE LIST THE EVENTS YOU COMPETE IN AND YOUR BEST TIME/PERFORMANCE AND DATE
1. Event: Time/Score: Date:
2. Event: Time/Score: Date:
3. Event: Time/Score: Date:
4. Event: Time/Score: Date:
5. Event: Time/Score: Date:
6. Event: Time/Score: Date:

Academic Information
High School:
Address
Guidance Counselor
Counselor Phone/Email:
GPA		Grad Yr.
Class Rank:		Class Size:
PSAT Written: PSAT Verbal: PSAT Math: SAT Written: SAT Verbal: SAT Math: ACT English ACT Written ACT Math ACT Science Composite ACT Score
SAT II List Subject Names and Scores
AP Courses Test Scores
Academic Interests
Academic Honors
Community Activities
Have you submitted an application? no yes
Would you like to receive an application? no yes
Are you applying early decision? no yes
Will you be applying for financial Aid? no yes
Have you completed your CSS/Profile? no yes
Are you planning a campus visit? no yes When?
List in order of preference, the Colleges you are interested in attending (including Brandeis)
1.
2.
3.
4.