Agnes Scott College Request for Information Form Contact Information * indicates required field. First Name* Preferred First Name Middle Name Last Name* Birthdate* January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 Gender* Female Male Email Address* Mailing Address* Country Afghanistan Aland Islands Albania Algeria Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Ashmore and Cartier Islands Australia Austria Azerbaijan Bahamas, The Bahrain Bangladesh Barbados Bassas Da India Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius, and ... Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Clipperton Island Cocos Islands (Keeling Islands) Colombia Comoros Congo (Brazzaville) Congo (Kinshasa) Cook Islands Coral Sea Islands Costa Rica Cote D'Ivoire Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Europa Island Falkland Islands (Islas Malvi... Faroe Islands Federated States of Micronesia Fiji Finland France French Guiana French Polynesia French Southern and Antarctic... Gabon Gambia, The Georgia Germany Ghana Gibraltar Glorioso Islands Greece Greenland Grenada Guadeloupe Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Isl... Honduras Hong Kong S.A.R. Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Jan Mayen Japan Jersey Jordan Juan De Nova Island Kazakhstan Kenya Kiribati Korea, North Korea, South Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau S.A.R. Macedonia, The Former Yugosla... Madagascar Malawi Malaysia Maldives Mali Malta Man, Isle of Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Norway Oman Pakistan Palau, the Pacific Islands of Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South S... South Sudan Spain Spratly Islands Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tromelin Island Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Islands Western Sahara Yemen Zambia Zimbabwe Street City State Select State Alabama Alaska American Samoa APO/FPO (AA) APO/FPO (AE) APO/FPO (AP) Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Mariana Islands Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands, U.S. Virginia Washington West Virginia Wisconsin Wyoming Postal Code *Country of Primary Citizenship Afghanistan Aland Islands Albania Algeria Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Ashmore and Cartier Islands Australia Austria Azerbaijan Bahamas, The Bahrain Bangladesh Barbados Bassas Da India Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius, and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Clipperton Island Cocos Islands (Keeling Islands) Colombia Comoros Congo (Brazzaville) Congo (Kinshasa) Cook Islands Coral Sea Islands Costa Rica Cote D'Ivoire Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Europa Island Falkland Islands (Islas Malvinas) Faroe Islands Federated States of Micronesia Fiji Finland Foreign/Unknown France French Guiana French Polynesia French Southern and Antarctic Lands Gabon Gambia, The Gaza Strip Georgia Germany Ghana Gibraltar Glorioso Islands Greece Greenland Grenada Guadeloupe Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong S.A.R. Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Jan Mayen Japan Jersey Jordan Juan De Nova Island Kazakhstan Kenya Kiribati Korea, North Korea, South Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau S.A.R. Macedonia, The Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Man, Isle of Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Norway Oman Pakistan Palau, the Pacific Islands of Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Sudan Spain Spratly Islands Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tromelin Island Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Islands Western Sahara Yemen Yugoslavia Zambia Zimbabwe Cell Phone Number Home Phone Number With which of the following do you identify? (Can select multiple.) American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific White Do you self-identify as Hispanic? Yes No Additional Information Student Type* Traditional Transfer Joint-Enrollment Student Type Definitions: Traditional: You are a traditional student if you are currently earning your high school diploma or equivalent. Transfer: You are a transfer student if you have earned transferable college credit after you earned your high school diploma or equivalent. Joint Enrollment: You are a current high school senior interested in earning college credit by taking classes at ASC. (open to women and men) Anticipated Start Term* Fall 2022 Fall 2023 Fall 2024 Fall 2025 Fall 2026 Fall 2027 Current School Name* School CEEB: Attended FROM Year (YYYY)* Attended TO Year (YYYY)* Academic and Extracurricular Information (optional) Academic Interest(s) Africana Studies Anthropology Art - History Art - Studio Artificial Intelligence Asian Studies Astrophysics Biochemistry and Molecular Biology Biology Business Management Chemistry Chinese Classics Computer Science - Dual Degree Dance Economics Education Engineering - Dual Degree English Literature English Literature - Creative Writing Environmental and Sustainability Studies Film and Media Studies French German Studies History International Relations Japanese Mathematics Mathematics - Economics Mathematics - Physics Music Neuroscience Nursing - Dual Degree Philosophy Physical Education Physics Political Science Pre-Law Program Pre-Medical Program Psychology Public Health Religion & Social Justice Religious Studies Sociology and Anthropology Spanish Theatre Undecided Women's Studies Please select any sports you are interested in playing at the NCAA Division III level. Basketball Cross Country Soccer Softball Tennis Volleyball Submit Agnes Scott College 141 E. College Ave. Decatur, Georgia 30030 CONTACT US SITE INDEX DIRECTORY MAPS & DIRECTIONS EMPLOYMENT OPPORTUNITIES EVENT RENTALS BRADLEY OBSERVATORY BOOKSTORES THE DALTON GALLERY MCCAIN LIBRARY CONSUMER INFORMATION Support Agnes Scott Your gift to the college is more valuable than ever as we address the known needs of today and anticipate what may come tomorrow. instagram twitter facebook youtube linkedin © 2020 Agnes Scott College. All rights reserved. PrivacyTitle IXAccreditationNondiscrimination Policy AGNES SCOTT COLLEGE CONSENT FORM FOR COLLECTING PERSONAL DATA IN/FROM EUROPEAN UNION (Required by European Union General Data Protection Regulation 2016/679 (“EUGDPR”)) The purpose of this consent form is to inform any European Union individual of Agnes Scott College’s collection and potential use of personal data provided by you. Agnes Scott College (“ASC”) is the controller of your personal data. You may contact Agnes Scott College at 141 E. College Avenue, Decatur, GA, 30030, or by phone and email at: 404-471-6285 or admission@agnesscott.edu. Your personal data will be used for your consideration for admission and/or enrollment, marketing academic programs and communicating University activities and accomplishments. The categories of personal data you are being asked to consent to ASC’s collection and use are your name, address, email address, IP address, telephone number and education history, test scores, ethnicity and possible college majors. ASC will share your personal data with third-party software providers who collect, store and process your personal data on behalf of the college and who are contractually obligated to keep your personal data confidential subject to appropriate safeguards to prevent it from unauthorized disclosure. The college also intends to share your personal data with: Human Capital Research Corporation, GDA, RuffaloNoelLevitz, RaiseMe Your personal data will be transferred out of the European Union to Agnes Scott College located in the United States. Your personal data will be stored in accordance with the record retention requirements applicable to Agnes Scott College and any other applicable U.S. laws. Under the EUGDPR, you have the right to request access to, rectify, erase and restrict the processing of your personal data. You also have the right to revoke this consent to use your personal data. If you feel the University has violated the EUGDPR, you have the right to file a complaint with the appropriate EU supervisory authority. These rights are more specifically described in the Privacy Notices posted on the college website at www.agnesscott.edu. I understand that by submitting this form, I consent to Agnes Scott College using my personal data for the purposes described in this notice and understand that I can withdraw my consent at any time. ConsentDecline