MARK APPROPRIATE ITEMS:

PERSONAL DATA:

Title: Ms. Mrs. Mr.

Full Name: __________________________________________________________________

Nickname: ___________________________ E-mail Address: ________________________

Permanent Address: __________________________________________________________

City: _______________________ State: ___________ ZIP: ___________

Country: _________________________

Mailing Address: (if different than permanent) __________________________________________________________

City: _______________________ State: ___________ ZIP: ___________

Country: _________________________

Home Phone: _________________ Best time to reach me: ______________________________

Cell Phone: _________________ Best way to reach me: ______________________________ IM Screen Name: ______________________________

Social Security Number: ___________________________ Date of Birth: _________________

Country of Citizenship: ____________________________

Relationship: Father Stepfather Guardian Spouse

Name: _______________________________

Address: _______________________________________

City: _______________________ State: ___________ ZIP: ___________

Home Phone: _________________________ Best way to contact: _______________________

Cell Phone: _________________________ Email: _______________________

Employer: ______________________________________ Occupation: ___________________

Work Phone: ______________________________________ Can you be contacted at work: ___________________

College (if any): ___________________________ Dates of Attendance: ______________________

Degree: ____________________________

Relationship: Mother Stepmother
Name: _______________________________

Address: _______________________________________

City: _______________________ State: ___________ ZIP: ___________

Home Phone: _________________________ Best way to contact: _______________________

Cell Phone: _________________________ Email: _______________________

Employer: ______________________________________ Occupation: ___________________

Work Phone: ______________________________________ Can you be contacted at work: ___________________

College (if any): ___________________________ Dates of Attendance: ______________________

Degree: ____________________________

ALUMNI CONNECTIONS:

List friends and/or relatives by name who attend or have attended Lebanon Valley College and have influenced your interest in LVC.

                 Name            Relationship     Dates of Attendance

     __________________________  ____________     ____________________

     __________________________  ____________     ____________________

     __________________________  ____________     ____________________

INTENDED MAJOR:

Major: If uncertain, write "open".

Please note:
Physical Therapy's deadline is February 1.
Early Childhood and Elementary/Middle Education's deadline is March 1.
Music, Music Education, Music Recording Technology, and Music Business majors must schedule an audition with the music department by March 1.

HONORS:

Briefly describe any scholastic/athletic distinctions or honors you have achieved during your academic career:

ACTIVITIES:

Please list your principal extracurricular activities and offices/positions held in order of interest to you. Circle those activities in which you hope to participate at Lebanon Valley.

SPORTS:

Please list sports in which you currently participate and circle those in which you hope to participate at Lebanon Valley.

EDUCATIONAL DATA:

High School: _________________________________________

High School CEEB code: _________________

Address: _______________________________________

City: _______________________ State: ___________ ZIP: ___________

Year of Graduation: __________________

School Telephone: _______________________

High School Counselor: _____________________________

SAT/ACT
Submission of SAT/ACT test results is optional for Admission.

Do you wish to have SAT/ACT test results considered by the Admission Advisory Group? ____Yes ____No

COLLEGE TRANSFER DATA:

If you are transferring, list the college(s) you previously attended along with dates of attendance:

                  College                  City/State/Country      Dates of Attendance  Dates Held/Expected   Date Degree Received/Expected

  _______________________________________ _______________________  ___________________  ___________________    ____________________

  _______________________________________ _______________________  ___________________  ___________________    ____________________

Please attach a separate page briefly describing your experiences at your current and/or previously attended colleges/universities and your reasons for transferring.

ADDITIONAL INFORMATION:

How did you first learn of Lebanon Valley College?

If necessary, attach a separate page describing any information that you feel the Admission Advisory Group should know about you before considering your application for admission to Lebanon Valley College.

UNDERSTANDING:

In signing this formal application, I signify the information provided is to the best of my knowledge and belief, accurate and correct. I have attached the non-refundable application fee of $30, check or money order, payable to Lebanon Valley College.

    ____________________________________________   __________________
                      Signature                            Date

SUPPLEMENTAL INFORMATION - Please Complete

Your participation is optional, but this information is necessary for the submission of governmental reports and to meet individual student needs. This information will not affect the admission decision.

Racial/Ethnic Identity: Black (non-Hispanic) Hispanic/Latino White (non-Hispanic) Asian or Pacific Islander American Indian/Alaska Native Other: