Your General Information

First Name: 	
Middle Name: 	
Last Name:  	
E-Mail Address: 	
Birth Date:		
Address:  		
City: 		
State or Country: 	
Zip Code:  		
Home Phone: 	
Cell Phone: 	
Height:  		
Weight: 		

Father's Name: 	
Occupation:  	
Alma Mater: 	
Work Phone/Email:	
Cell Phone:  	

Mother's Name: 	
Occupation:  	
Alma Mater: 	
Work Phone/Email:	
Cell Phone:  	
Brothers(Name/Age): 	
Sisters (Name/Age): 	

High School Information

High School: 	
Graduation Date: 	
Address:  		
City: 		
State or Country: 	
Zip Code:  		
Phone Number: 	
NCAA Clearinghouse Number:  
Social Security Number:   
GPA: 		
SAT Verbal Score: 	
SAT Math Score: 	
SAT Writing Score: 	
ACT Composition/Average: 
Planned Major:  	

Athletic Information

High School Coach: 	
Phone Number/Email:
Cell Phone Number:  	
Club Team: 	
Club Coach: 	
Phone Number/Email:
Cell Phone Number:  	

Please list your primary position(s): 


Please list your athletic accomplishments (personal bests, rankings, awards, etc): 	


Other Information


Do you know anyone who has attended UCLA? Who?


Do you know anyone currently attending UCLA? Who?



Why are you interested in UCLA? 


List the top three universities of your choice (in order of preference - include UCLA if appropriate)