STUDENT DATA FORM Mail Completed Questionnaire to: Second Tassel Scholarship Services Department RCA Computer Processing Fee:$49 PO Box 2207 Littleton CO 80161 HC76 ============================================================================ ALL INFORMATION PROVIDED FOR THIS FORM WILL BE HELD IN THE STRICTEST CONFIDENCE AND WILL NOT BE SHARED WITH ANY SCHOOL OR AGENCY UNLESS YOU INSTRUCT US TO DO OTHERWISE. ============================================================================ _._._._._._._._._._._. _. _._._._._._._._._._._._._._._._. _._._._._._. First Name MI Last Name DATE _._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._. Street Address Apartment No. _._._._._._._._._._._._._._._._. _._._._._._._._._._. _._._._._. City State Zip Code _._._._._._._._._._._._._._. County (_._._.)_._._.-_._._._. SEX _. Birthdate _._._._._._. Telephone (area code, too) M or F M M D D Y Y School now attending ________________________ __________________ ________ City State Year in School _. Type of School _. Citizenship _. HS Freshman = 1 Public = 1 US Citizen = 1 HS Sophomore = 2 Private = 2 Applied for = 2 HS Junior = 3 Religious = 3 HS Senior = 4 Vocational = 4 HS Grad (not in school) = 5 College Freshman = 6.1 Approximate Rank in Class _. College Sophomore = 6.2 Upper 5%= 1, Upper 15%= 2, Upper 30%= 3 Upper 50%= 4, Upper 75%= 5, Lower 25%= 6 Copyright(C), 1988 Academic Guidance Services All Rights Reserved. Page 1 OCCUPATIONAL GOALS: List as many as 12 occupations you are considering on the lines below, in order of greatest interest: 1)______________________________ 7)______________________________ 2)______________________________ 8)______________________________ 3)______________________________ 9)______________________________ 4)______________________________ 10)______________________________ 5)______________________________ 11)______________________________ 6)______________________________ 12)______________________________ RELIGIOUS AFFILIATION: ____________________________________________________________ RACIAL OR ETHNIC BACKGROUND: List as many as 4 in the following spaces. (Examples: Armenian, American Indian, Canadian, Chinese, Greek, Russian, Spaish speaking, etc.) ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ CLUBS OR ORGANIZATIONS: List up to 5 in which you are currently a member. (Examples: Boy Scouts, Boys State, Demolay, 4-H, Girl Scouts, Junior Achievement, National Honor Society, YMCA, B'nai B'rith, etc.) ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ SPECIAL TALENT OR SKILL: If you are especially talented or skillful in a particular area and would be willing to compete for an award or prize, write the area of your skill below. You may list up to 8. (Examples: Art, Bowling, Cartooning, Dance, Debate, French, 4-H, Math, Music, Photography, Public Speaking, Beauty Pageant, Writing, Sewing, etc.) ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Copyright(C), 1988 Academic Guidance Services All Rights Reserved. Page 2 PARENTS CLUB OR ORGANIZATION MEMBERSHIP: List as many a 5 clubs or organizations to which your parents currently belong. (Examples: Eagles Lodge, K. of C., Masonic Temple, American Legion, etc.) ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ PARENTS EMPLOYMENT: Give the name of the Company or Companies for which your parents work or have worked. (If the company is a subsidiary of another company, give the name of the parent company.) Please INCLUDE military service as employment. Company ____________________________________________________________ Working or Retired _______________________________________________________ Years with Company _____ Company ____________________________________________________________ Working or Retired _______________________________________________________ Years with Company _____ Company ____________________________________________________________ Working or Retired _______________________________________________________ Years with Company _____ Company ____________________________________________________________ Working or Retired _______________________________________________________ Years with Company _____ ARMED FORCES: if one or both of your parents have served in the Armed Forces, print the name of the branch and division below and include whether a veteran or not. ____________________________________________________________ ____________________________________________________________ Copyright(C), 1988 Academic Guidance Services All Rights Reserved. Page 3 PARENTS DECEASED, DISABLED OR RETIRED: Check the appropriate box for any of the following which apply. Parent is deceased and was a member of one or more of the following: __/ Fraternal Order of the Eagles __/ Knights of Columbus __/ Died as a result of service with any branch of the military __/ 1st Infantry Division in Vietnam __/ 2nd Marine Division __/ 3rd Marine Division __/ Coast Guard __/ Experimental Test Pilot Parent is deceased and you are: __/ Receiving Social Security Benefits __/ Dependent of a company signatory to Maritime Advancement Program Parent is deceased or totally disabled as a result of one of the following: __/ Military Service __/ WWI, WWII, Korea, Vietnam __/ 4th Marine Division __/ 5th Marine Division Parent is retired from: __/ Air Force __/ Navy or Marine Corps __/ Regular Army-as an Officer __/ Any occupation that receives Social Security Benefits LABOR UNIONS OR EMPLOYEE ASSOCIATIONS: List up to 4 Labor Unions or Associations to which your parents belong: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Copyright(C), 1988 Academic Guidance Services All Rights Reserved. Page 4 YOUR PRESENT EMPLOYMENT: List the titles of your present occupation, if you are employed. (Examples: Armed Forces, Food Store Worker, Newspaper Delivery Person, Caddy, etc.) ____________________________________________________________ ____________________________________________________________ YOUR PREVIOUS EMPLOYMENT: List the titles of your previous occupations, if you have been employed in the past. ____________________________________________________________ ____________________________________________________________ PHYSICAL DISABILITY OR HANDICAP: If you have a physical disability or handicap, check the appropriate box. __/ Physical Disability __/ Handicap COLLEGES YOU ARE CONSIDERING: List in order of preference those colleges in which you may be particularly interested in attending. You may list up to eight. Please show State in which each institution is located. 1. College ____________________________________________________________ State ____________________________________________________________ 2. College ____________________________________________________________ State ____________________________________________________________ 3. College ____________________________________________________________ State ____________________________________________________________ 4. College ____________________________________________________________ State ____________________________________________________________ 5. College ____________________________________________________________ State ____________________________________________________________ 6. College ____________________________________________________________ State ____________________________________________________________ 7. College ____________________________________________________________ State ____________________________________________________________ 8. College ____________________________________________________________ State ____________________________________________________________ YOUR FAMILY'S TOTAL INCOME IS APPROXIMATELY: Check the most appropriate box. __/ Below $6,000 __/ $13,001 - $17,000 __/ $6,001 - $9,000 __/ $17,001 - $20,000 __/ $9,001 - $13,000 __/ $20,001 - $32,000 __/ Above $32,000 Copyright(C), 1988 Academic Guidance Services All Rights Reserved. Page 5