APPLICATION FOR UNDERGRADUATE ADMISSION AND SCHOLARSHIP to Rockhurst University or Research College of Nursing PERSONAL DATA Please Print or Type Mr. Miss Mrs. Ms. SOCIAL SECURITY NUMBER (OPTIONAL) FULL LEGAL NAME (FIRST, MIDDLE, LAST) MAIDEN PREFERRED NAME HOME ADDRESS APT. NUMBER CITY STATE ZIP HOME PHONE CELL PHONE MAILING ADDRESS (IF DIFFERENT FROM ABOVE) WORK ADDRESS CITY STATE ZIP PHONE DATE OF BIRTH PLACE OF BIRTH CITY, STATE, COUNTRY E-MAIL ADDRESS COUNTRY OF CITIZENSHIP VISA STATUS (INTERNATIONAL STUDENTS) Permanent Resident of U.S.? Yes No Preferred method of contact: Home Phone Cell Phone E-mail May we contact you by cell phone? Yes No I would like to receive a text message upon my admission to Rockhurst University and for other important events. Will you graduate with an A+ certification from your high school (Missouri Residents only)? Yes No OPTIONAL PERSONAL DATA (Check more than one if applicable.) Do you consider yourself to be Hispanic/Latino? Yes No Religion: Select one or more of the following racial categories to describe yourself: Catholic Protestant American Indian or Alaskan Native Hispanic Jewish Muslim Asian White Other (specify): Black or African American What languages are spoken in your home? FAMILY DATA For First Time College Students Only Living Deceased Rockhurst Alumnus Yes No FATHER S / MALE GUARDIAN S FULL NAME, INCLUDING SALUTATION (MR., DR., ETC.) HOME ADDRESS APT. NUMBER CITY STATE ZIP PHONE EMPLOYER / COMPANY TITLE / POSITION WORK PHONE E-MAIL ADDRESS COLLEGE(S) ATTENDED (IF ANY) SCHOOL, STATE, DEGREE Living Deceased Rockhurst Alumna Yes No MOTHER S / FEMALE GUARDIAN S FULL NAME, INCLUDING SALUTATION (MS., MRS., DR., ETC.) HOME ADDRESS APT. NUMBER CITY STATE ZIP PHONE EMPLOYER / COMPANY TITLE / POSITION WORK PHONE E-MAIL ADDRESS COLLEGE(S) ATTENDED (IF ANY) SCHOOL, STATE, DEGREE NAMES AND YEAR OF HIGH SCHOOL GRADUATION OF BROTHERS AND SISTERS:
ADMISSION CLASSIFICATION Year of desired Fall Freshman Full time Have you previously submitted entrance: Spring Transfer Part time an application to Rockhurst or Summer International Research College of Nursing? No Yes: when? COLLEGE PLANS AREAS OF STUDY OFFERED: Undergraduate Accounting American Humanics* Art* Biochemistry Biology Business Administration Business Communication Catholic Studies* Chemistry Clinical Laboratory Sciences Communication Communication Sciences & Disorders Economics Education (Elementary) Education (Secondary) English Exercise and Sport Science Finance/Accounting Finance/Economics French German* Global Studies History International Business Journalism* Management Marketing Mathematics Music* Nonprofit Leadership Studies Nursing Organizational Leadership Studies Paralegal Studies* Philosophy Physics Physics of Medicine* Political Science Psychology Spanish Speech Pathology Theater Arts* Theology and Religious Studies Women s Studies* Writing* Pre-professional Pre-Dentistry Pre-Engineering Pre-Law Pre-Medical Post-Baccalaureate* Pre-Medicine Pre-Occupational Therapy Pre-Optometry Pre-Osteopathic Medicine Pre-Pharmacy Pre-Physical Therapy Pre-Physician s Assistant Pre-Veterinary Medicine Graduate Doctor of Physical Therapy Master of Education Master of Occupational Therapy Master of Science in Communication Sciences and Disorders Master of Business Administration Fifth-year MBA Executive Fellows MBA DO/MBA Dual Degree (In conjunction with the Kansas City University of Medicine and Biosciences) * Program offered only as minor or certificate Areas of study: First choice Second choice EDUCATIONAL BACKGROUND LIST ALL HIGH SCHOOLS ATTENDED CITY STATE YEARS OF ATTENDANCE DATE OF GRADUATION HIGH SCHOOL CODE Have you taken the ACT? Yes; date taken: No; I plan to take it on: Have you taken the SAT? Yes; date taken: No; I plan to take it on: International students: Have you taken the TOEFL? Yes; date taken: No; I plan to take it on: LIST ALL COLLEGES AND UNIVERSITIES ATTENDED (DURING HIGH SCHOOL & BEYOND) YEARS OF ATTENDANCE DATE OF GRADUATION If you did not graduate from high school, have you taken the GED (General Education Development) Test? (If yes, please arrange to have official GED scores sent to Rockhurst University from the respective state agency.) Yes No COURSEWORK IN PROGRESS List all high school and college courses you plan to complete from now until enrolling at Rockhurst University or Research College of Nursing.
EXTRACURRICULAR ACTIVITIES List your extracurricular, community, employment and religious-affiliated activities. Include specific events and/or major accomplishments such as offices held, varsity letters, honor roll, etc. Please check ( ) in the right column those activities you hope to continue in college. This section is used to determine eligibility for the service scholarships. Attach a separate sheet, if necessary. ACTIVITY YEARS OF PARTICIPATION POSITIONS OR HONORS WON PARTICIPATION IN COLLEGE? What are your primary reasons for applying to Rockhurst University or Research College of Nursing? If there have been any circumstances that may have affected your academic record, please explain below. Have you ever been dismissed from any school for disciplinary reasons? Yes No If answered yes, please attach an explanation. Have you ever been convicted of, or pleaded guilty to, a felony? Yes No If answered yes, please attach an explanation. FINANCIAL ASSISTANCE Do you plan to apply for financial aid? Yes No HOUSING INFORMATION I plan to: Live on campus Live with my parents Live off campus (Please see requirements to determine eligibility.)
SUPPLEMENTARY INFORMATION Please list any of your relatives who attend(ed) Rockhurst University or Research College of Nursing. Please state the relationship to you and, if applicable, when the relative graduated. This section is used to determine eligibility for alumni scholarships and family awards. How did you first learn about Rockhurst University or Research College of Nursing? Which of the following were the most influential in your decision to apply to Rockhurst University or Research College of Nursing? Assign a one (1) to the most influential; two (2) to the second most influential, etc. Admission Counselor Current Student Rockhurst Web Site Advertising Friends Rockhurst/Research Alumni Brochures Open House School Counselor Campus Visit Parents Teacher College Guide Book Other (please specify): How much did the fact that Rockhurst is a Jesuit institution influence your decision to apply for admission? Very influential Moderately influential Slightly influential No influence Please list all other colleges and universities to which you have applied or plan to apply for admission: SIGNATURE I understand that I must submit complete official transcripts from all schools, colleges, or universities attended. I certify that, to the best of my knowledge, all statements I have made in this application are complete and true. Incomplete or false information may result in the denial of this application or in my subsequent dismissal from Rockhurst University or Research College of Nursing. SIGNATURE DATE No person acting within his or her authority and responsibility at Rockhurst University or Research College of Nursing shall discriminate on the basis of color, race, creed, gender, national origin, sexual orientation, disability, veteran s status or age.
RECOMMENDATION FOR ADMISSION to Rockhurst University or Research College of Nursing For First Time College Students Only The student completes Section I of this recommendation and submits the entire application to the secondary school counselor. After completing Sections II and III, the counselor will forward the recommendation, along with the admission application, transcripts and test scores to Rockhurst University. SECTION I Please Print or Type FULL NAME OF APPLICANT SOCIAL SECURITY NUMBER (optional) HOME ADDRESS STREET CITY STATE ZIP PHONE HIGH SCHOOL HIGH SCHOOL CODE SCHOOL ADDRESS STREET CITY STATE ZIP PHONE Sections II and III should be completed by the high school counselor or principal. SECTION II Percentage of senior class attending: Four-year colleges: % Two-year colleges: % Student s GPA: Weighted Unweighted Student s ACT standard scores are: E M R SR C Date taken: Rockhurst does not require the writing portion of the ACT. Student s SAT standard scores are: V/CR M Writing (if applicable) Date taken: This student ranks exactly, or approximately from the top in a class of. We do not rank. RANK CLASS SIZE This student s course selection, among those available at your school, is: Most Demanding Demanding Average Below Average SECTION III I would rank this student s academic ability and motivation as follows: BELOW AVERAGE AVERAGE ABOVE AVERAGE EXCELLENT EXTRAORDINARY Ability Motivation I would recommend this student s academic promise, character, and personal promise as follows: NOT WITHOUT RECOMMENDED ENTHUSIASM MODERATELY STRONGLY ENTHUSIASTICALLY Academic Promise Character Personal Promise
RECOMMENDATION FOR ADMISSION to Rockhurst University or Research College of Nursing (continued) PLEASE RESPOND TO THE FOLLOWING QUESTIONS. Have any outside circumstances interfered with this student s academic achievement? Yes No If yes, please explain. Is there a great variance between test scores, grades and motivation? Yes No If yes, please explain. Is there a set of grades during any marking period that is not consistent with the overall performance? Yes No If yes, please explain. Please write a statement about the candidate commenting on the particular qualities he or she possesses that you feel would make the candidate qualified for admission to Rockhurst University. (Please address any questions marked yes above.) PLEASE FORWARD THIS FORM WITH A COMPLETE TRANSCRIPT AND TEST SCORES TO: Office of Admission Rockhurst University 1100 Rockhurst Road Kansas City, MO 64110-2561 COUNSELOR S SIGNATURE DATE COUNSELOR S NAME PHONE NUMBER COUNSELOR S E-MAIL ADDRESS