Student Application For College In High School Page 2
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1
2
3Student Application for College in High School
(Note: You are to fill out and submit only one application)
Social Security Number
-
-
Last Name
First Name
Mid. Initial
Permanent Address
City
State
Zip
Telephone Number
(
)
-
High School
Expected Grad. Date
-
Month – Year
Have you ever applied to any University of Pittsburgh campus before (including the College in High School
program)?
Yes
No
DEMOGRAPHIC INPORMATION: The demographic information collected on this side of the form is designed to provide the
institution with ethnic, sex, disability and citizenship data on all applicants. The data are used by the University to respond to the
requests of governmental agencies for aggregated summary information that must be provided by law. This information will not be
used by the University in making admission decisions, nor will the information on individual students be released outside the
University without the written permission of the student.
Date of Birth
Sex
Us Citizen
-
-19
Male
Female
Yes
No
Ethnicity
Black
Asian/Pacific Islander
Hispanic
White
Native American
Indian/Alaskan
Residency
Are you a Resident in Pennsylvania?
Yes (more than one year)
Yes (less than one year)
No
Is your father/guardian a resident of PA?
Yes (more than one year)
Yes (less than one year)
No
Is your mother/guardian a resident of PA?
Yes (more than one year)
Yes (less than one year)
No
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