Ancilla College Application

* - Indicates required field

Personal Information:
Name: *
Former Name:
Indicate any former name(s) under which educational records are listed.
Email:
Please replace with valid email address.
Social Security No: *
Address: *
City: *   State: *   Zip: * 
County of
Residence: *
Citizenship
Country: *
Home Phone: *
Work Phone:
Date of Birth: *   (mm/dd/yy)
Gender: Male   Female
Marital Status: Single   Married
Residency: U.S. Citizen
Eligible Non-Citizen
      (Send copy of: I-151, I-551, or I-94)
International Student
      (Must send Visa documentation)
Parent/Guardian/Spouse:  
(if under 21)
Parent/Guardian
e-mail:
Phone:
Address:
City:   State:   Zip: 
Ethnic Data: (optional)
Reporting racial and ethnic data is required by state and federal laws pertaining to civil rights. 		 A - American Indiana/Alaskan Native
 B - Asian
 C - Black or African American
 D - Hispanic
 E - Native Hawaiian or other Pacific Islander
 F - Non-resident Alien
 G - White
Grants & Scholarships: Are you interested in being considered for any Ancilla grants or scholarships?
Yes   No
Religious Affiliation:(optional)  Catholic
 Non-Catholic
 Other
Veteran:
Yes   No
If you are or have been in the Armed Forces, you must submit a copy of your service record (DD214).
 
Term of Entry:
When do you plan to start at Ancilla as a degree student?  
Spring (Jan) 2012
Summer I - 2012
Summer II - 2012
Fall 2012
Other
Education Status: When you enter Ancilla College, you ...
Will be entering college for the first time.
Will be transferring from another college.
      Indicate number of credit hours  
      0-29          30-60          with degree
Previously attended Ancilla College
Will be an Early Bird Student
Degree and Major:
Associate Degrees:

Behavioral Science
Business Administration
Criminal Justice
Early Childhood Education
Education
Elementary Education
General Studies
Health Science
History
Mass Communication
Nursing - ASN
Nursing - LPN-RN
Pre-Allied Health
Professional Health Sciences
Science
Secondary Education
Undecided/Transferring

Certificate Programs:
Church Organist
Do you plan to transfer Ancilla credits to another school?  Yes    No
If yes, which school?  
Education:  High School    GED
Date of High School Graduation or GED:
Name and address of the high school currently attending or last attended:
Name:
City:   State:   Zip: 
My intention is to... (check all that apply)
Take summer courses only.
Take only 1 or 2 courses.
Be a part-time student.
Take courses, but do not plan to earn a degree.
Be a full-time student.
Complete my degree at Ancilla College.
Transfer credits to another school or university.
College Transcripts:
List the full name of all colleges, universities, technical schools, and other institutions attended or are currently attending (other than high school) beginning with the most recent. If you have not attended any post-secondary institution, write "none". Failure to indicate all institutions attended may result in denial of admissions or termination of enrollment.
Institution:
City:   State:  
Attendance Dates: from (mm/yy) to (mm/yy)
Transcripts Requested Date: (mm/yy)
Are you currently attending?   Yes   No
Institution:
City:   State:  
Attendance Dates: from (mm/yy) to (mm/yy)
Transcripts Requested Date: (mm/yy)
Are you currently attending?   Yes   No
Institution:
City:   State:  
Attendance Dates: from (mm/yy) to (mm/yy)
Transcripts Requested Date: (mm/yy)
Are you currently attending?   Yes   No
Please make sure arrangements with all colleges and universities attended to have your official transcript(s) sent as soon as possible to the: Office of Admissions, Ancilla College, P.O. Box 1, Donaldson, IN 46513-0001.
Privacy: May we release your telephone number to student directories or other university publications?  Yes   No
I am interested in playing: 
Cheerleading
Men's Baseball
Men's Basketball
Men's Golf
Men's Soccer
Women's Basketball
Women's Golf
Women's Softball
Women's Volleyball
Emergency Information:
Person to contact in case of emergency:   
Address:
City:   State:   Zip: 
Day Phone: Eve Phone: 
Relationship to emergency contact person: 
How did you hear about Ancilla College?
Signature: I certify that the information provided on this application is accurate and true. I understand that falsified information may result in denial of admission and/or termination of enrollment at Ancilla College. I agree to abide by the policies, rules and regulations of Ancilla College. I authorize my high school to furnish all academic and personal information requested by the Admissions Office of Ancilla College. I authorize Ancilla College to report my academic progress to my counselor for the purposes of curriculum development and improvement of instruction. I authorize the Office of Financial Aid to release, as it deems appropriate, information on my academic program (including grades) and the amount of any award I may receive to agencies, institutions, and others involved in providing funds for my education.
Date: *   (mm/dd/yyyy)
Signature: *
(enter full name)