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Application for Undergraduate Admission

Personal Information
Your Full Legal Name:
Last
Maiden
First
Middle
Preferred Name
Home Address:
Number and Street


City
State
Zip Code
Country (If not USA)
Preferred Phone Number: (Please select a phone number type)
Secondary Phone Number: (Please select a phone number type)
Email Address:
Preferred Method of Contact:
Current Mailing Address (if different from above):
Number and Street


City
State
Zip Code
Date Address is No Longer Active
Marital Status:
Are you a U.S. Citizen?
If you are not a U.S. citizen, please list your country of citizenship
First Language: (if other than English)
Language Spoken at Home: (if other than English)
Country of Birth: (If not USA)
Date of Birth:	(mm/dd/yy)
Religious Preference (optional):
Gender:
Select one or more races from the following groups. (optional) American Indian or Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander White or Caucasian
Are you of Hispanic or Latino Origin Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race (optional)	Yes No
Enrollment Information
What major are you interested in studying? (If you're not sure, you can put 'Open')	Other:
Are you applying for admission to the pre-physical therapy program?	Yes If yes, please select an undergraduate major for the Major field above.
Enrolling As:
	If returning to Clarke, years attended Clarke:
Enrollment Term:
Intended Residence:
	(Students under age 22 must live with family or on campus.)
Intended Credit Load:
Referral Information
List anyone who referred you to Clarke University, including their relationship to the university (alum, current student, friend of the university, etc.) You may choose up to 3 referrals:
Referral 1:
Name:
Relationship to the Applicant:
Relationship to the Unversity: If an alum, please provide years of attendance.	Alum Years of Attendance:
Referral 2:
Name:
Relationship to the Applicant:
Relationship to the Unversity: If an alum, please provide years of attendance.	Alum Years of Attendance:
Referral 3:
Name:
Relationship to the Applicant:
Relationship to the Unversity: If an alum, please provide years of attendance.	Alum Years of Attendance:
Family Information
Please select the primary person to whom you would like parent/guardian information to be sent.

Last Name
First Name
Mailing Address: (if different from yours)
Number and Street

City
State
Zip Code
Cell Phone:
Email Address:
Employer:
Position:
Highest Degree Earned:
If other, please specify:
Are you his/her first child to go to college?	Yes No
Please select the secondary person to whom you would like parent/guardian information to be sent.

Last Name
First Name
Mailing Address: (if different from yours)
Number and Street

City
State
Zip Code
Cell Phone:
Email Address:
Employer:
Position:
Highest Degree Earned:
If other, please specify:
Are you his/her first child to go to college?	Yes No
Brothers and Sisters (still in school):
1- Full Name
Age
School Attending
HS Graduation Year
2- Full Name
Age
School Attending
HS Graduation Year
3- Full Name
Age
School Attending
HS Graduation Year
Relatives who are attending, have attended, or are currently employed at Clarke University:
1- Full Name
Relationship to You
Year(s) Attended / Employed - Department
2- Full Name
Relationship to You
Year(s) Attended / Employed - Department
High School Information
List the most recent high school attended and include date of graduation or anticipated date of graduation. If you have received your GED in lieu of graduation, please type GED for Name of High School.
Name of High School
City
State
Graduation/GED Date
What is the estimated size of your high school?
What is your estimated cumulative high school grade point average:
on a scale
Have you ever been placed on probation or dismissed by any high school you have attended?

If yes, please explain the circumstances below.

Interests Please check any of Clarke's varsity athletic teams for which you wish to be recruited.
Men's Baseball Basketball Bowling Cross Country Golf Soccer Track and Field Volleyball	Women's Basketball Bowling Cross Country Golf Soccer Softball Track and Field Volleyball
I am interested in the following types of collegiate activities: (Please select up to 6)





Other:
Standardized Test Information
Have you taken the ACT or SAT?
If yes, composite score?
If yes and retaking, date of retake:
If no, I plan to do so on:	(month/year)
If you are an international student:
Have you taken the TOEFL or IELTS?
If yes, score?
Date Taken:
If no, I plan to do so on:	(month/year)
Transfer Information
Beginning with the most recent, list all of the colleges and universities you have attended since high school whether or not you completed the coursework or earned any credit.
1- Name of Institution
City
State
Dates of Attendance
2- Name of Institution
City
State
Dates of Attendance
3- Name of Institution
City
State
Dates of Attendance
If you have attended more than three institutions, please list the remaining schools here.

What is your estimated collegiate cumulative grade point average?
on a scale
If you are a memeber of Phi Theta Kappa (community college academic honor society), please check here. Yes
Are you eligible for re-admission to the last college you attended?

If no, please explain the circumstances below.

Other Information
How did you first learn about Clarke University?
To which other colleges will you apply for admission?

List the primary influences that led you to apply to Clarke University:

By typing my name below, I certify that the information I am submitting in this online application is accurate to the best of my knowledge. Falsification of information on this application could jeopardize acceptance and enrollment. I authorize any schools or colleges I have previously attended or am currently attending to release my personal and academic information to Clarke University and/or its representatives. Further, I agree that my college grades may be used for statistical studies or sent to my high school or community colleges for evaluation purposes. I understand that official high school (or college) academic transcripts and the results of my ACT/SAT examination must be received by Clarke University before a final admission decision can be made. My signature also gives Clarke University permission to use photos of me in any promotional materials, print or electronic.
Your Name: Date:

Clarke University

Application for Undergraduate Admission