1. Name

First *
Last *

2. Permanent Address

Street *
City *
State *	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Washington DC Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

3. Home Telephone Number (include area code) *

4. Email *

5. Summer Address

6. Summer Start and End Dates

7. Summer Telephone Number (include area code) *

8. Summer Email (if different from above)

9. Fall Boarding School Address

10. Fall Start and End Dates (if different)

11. Fall Email (if different from above)

12. Birth Date (month/date/year) *

13. High School You Attend *

14. Anticipated High School Graduation Date *

15. Current GPA: * on a * scale.

16. Rank in class: * of * students.

17. Ethnicity (Optional)
If you wish to be identified with a particular ethnic group(s), check any that apply.

African American, Black
Hispanic, Latina
Puerto Rican
Native American, Alaskan
Native Mexican American, Chicana
White or Caucasian
Asian American
Native Hawaiian, Pacific Islander
Other Specify:

18. Parent 1 / Legal Guardian

A. Full Name *

B. Is he/she living? * Yes No

C. Home address if different from yours

Street *
City *
State *	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Washington DC Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

D. Occupation

E. Name of Employer

19. Parent 2

A. Full Name *

B. Is he/she living? * Yes No

C. Home address if different from yours

Street *
City *
State *	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Washington DC Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

D. Occupation

E. Name of Employer

20. Relatives *
Please list the names of any relatives or acquaintances who have attended Mount Holyoke College. Indicate their class year and relationship to you. If you are acquainted with MHC faculty or staff, please list them as well.

21. Extracurricular, Personal, and Volunteer Activities (including summer) *
List your most important extracurricular activities in the order of their importance to you. These can include interests and accomplishments such as earning a varsity letter, winning an award, playing an instrument, working in your community, etc. Include the activity, what grade levels you were involved with the activity, how many hours per week and weeks per year approximately you spend on the activity. Also include any positions held, honors won, or letters earned.

22. Courses *
Please list courses you anticipate taking in your junior year. Include subject areas (English, foreign language, math, history/social sciences, science, and other).

24. Essay
If you are selected to participate in Take the Lead, you will have the opportunity to plan and implement an action project aimed at addressing a specific issue in your school, community, or the world. Please tell us about some issue that concerns you. It could be something specific to your school or community, like the quality of food available in the cafeteria, or the litter in a nearby park; or it could be something more global, like racism, sexism, or the environment. Please discuss the topic that you would like to address and clearly describe the source of your concern, who it affects, how it affects them, and why you care.

A. Action Project Topic *

B. Please save your essay in word first and paste into the box below. *