Please enter your information in each of the following sections. Fields with a red asterisk (*) are required and must be completed before you can submit your application. Additional questions may become required based on your answers to a previous question.

Name

Prefix
Ms.
First Name*
KennaTest
Middle Name
LIsa
Last Name*
SmithTest
Maiden Name
Suffix
Ed.D.
Preferred First Name if Applicable
Kenna
Social Security Number
(required if you are applying for Financial Aid)
111111111
Birth Date
(mm/dd/yyyy)
7/2/2012

Permanent Address

Check if address is outside of U.S. or Canada
Yes
Address
3333 Regis Blvd
Address (cont)
A-12
City
Denver
Email Address*
krsmith@regis.edu
Foreign Address Line
Enter the 3rd line of the foreign address as it appears on the mailing label.
foreign address line 3
Country
Barbados

Contact

Home Phone*
303 455-1055
Cell Phone
303 455-1066

Temporary Address

Is current address different than permanent address?
If your current address is different than your permanent address, select Yes and fill out your address; otherwise, skip this section.
Yes
Check if address is outside of U.S. or Canada
No
Address
4536 east Lane
Address (cont)
apt 23
Temporary Address Foreign Address Line
foreign line 3
City
brooklyn
State/Province
Nebraska
Zip/Postal Code
10056
Attention
Telephone
718 555-1212
Temporary Address Effective Date
(mm/dd/yyyy)
10/18/2012
Temporary Address Expiration Date
(mm/dd/yyyy)
12/6/2012
Please enter your information in each of the following sections. Fields with a red asterisk (*) are required and must be completed before you can submit your application. Additional questions may become required based on your answers to a previous question.

Academic Plans

Anticipated Entry Term*
Admit Type*
New Student
Academic Program*
Business Administration: Finance
Career Goal 1*
doctor
Career Goal 2
nurse
Course Load*
Full Time

College Plans

Are you interested in campus housing?*
Residence Requirement: Residence Life is viewed by the University as an integral part of a student's complete educational experience. As such, students taking courses in Regis College or traditional nursing who are full-time (12 units or more), unmarried, and between the ages of 16 and 21 are required to reside on campus and take their meals on campus through University meal plans during their freshman year. There is no waiver for freshman from this policy except to live at home in the Denver metro area with parent(s) or guardian(s).
No
Have you previously applied?*
Yes
Year Previously Applied
2009
Month Previously Applied
August
Do you plan to apply for Financial Aid?*
Yes
Do you plan to apply for campus employment?*
Yes
Do you plan to apply for an honors program?
Yes
Do you plan to apply for a scholarship?
Yes
Do you plan to apply to study abroad?
Yes

Decision Factors

What is the primary factor influencing your decision to apply to Regis?
Campus Visit
What is the secondary factor influencing your decision to apply to Regis?
High School Visit
Please enter your information in each of the following sections. Fields with a red asterisk (*) are required and must be completed before you can submit your application. Additional questions may become required based on your answers to a previous question.

Citizenship

Citizenship Status*
Non-Resident Alien
Visa Type
C-1 Transit Visa
Primary Non-U.S. Citizenship
Angola
Years lived in the U.S.
5
Secondary Non-U.S.Citizenship
Andorra
Entry Date
(mm/dd/yyyy)
2/28/2012
Other Non-US Citizenship
Aland Islands
Currently living in the U.S.
Yes
Alien Registration Number
123456789
First Language
English
Birth Country
Belgium

Optional Ethnic Information

The information you provide in this section will not be used in a discriminatory manner.
Hispanic/Latino (including Spain)?
Non-Hispanic/Latino
Regardless of your answer to the prior question, please check one or more of the following groups in which you consider yourself to be a member:
American Indian or Alaska Native
Yes
Asian
Yes
Black or African American
Yes
Native Hawaiian or Other Pacific Islander
Yes
White
Yes

Additional Information (Optional)

The following items are optional. No information you provide will be used in a discriminatory manner.
Gender
Female
Are you the first member of your family to attend college?
Religious Affiliation
Catholic
Veteran
No
Please enter your information in each of the following sections. Fields with a red asterisk (*) are required and must be completed before you can submit your application. Additional questions may become required based on your answers to a previous question.

High School Credit

1

High School
Enter information about your school's location and click 'Search' to pick your school from a narrowed list.
Alak High School (020152)
Unlisted School Name and Address
If you cannot find your high school, or you were home schooled, please enter the school name and address below. Otherwise, leave this area blank.
Home Schooled
No
Attended From Month
March
Attended From Year
2009
Attended To Month
August
Attended To Year
2012
Graduated
No
Counselor's Position
Counselor's Prefix
Counselor's First Name
Counselor's Last Name
Counselor's Email
Counselor's Phone

2

High School
Enter information about your school's location and click 'Search' to pick your school from a narrowed list.
Biddeford High School (200105)
Unlisted School Name and Address
If you cannot find your high school, or you were home schooled, please enter the school name and address below. Otherwise, leave this area blank.
Home Schooled
No
Attended From Month
July
Attended From Year
2011
Attended To Month
October
Attended To Year
2012
Graduated
Counselor's Position
Counselor's Prefix
Counselor's First Name
Counselor's Last Name
Counselor's Email
Counselor's Phone
Did or will receive GED?
No

College Credit

Are you currently enrolled in college?*
Yes
Transfer Students: As of today have you completed 30 hours of college credit?
If you have not completed 30 semester hours or more at college, your high school transcript is required.
Yes

Colleges Attended

College 1

College
Enter information about your school's location and click 'Search' to pick your school from a narrowed list.
University of Alaska Southeast (4897)
Unlisted School Name and Address
If you cannot find your college, please enter the school name and address below. Otherwise, leave this area blank.
Attended From Year
2011
Attended From Month
March
Attended To Year
2012
Attended To Month
October
Are you currently attending this Institution?
Yes
Graduated
No
Degree Date
(mm/dd/yyyy)
10/24/2012
Degree Earned or Expected
Masters
Please enter your information in each of the following sections. Fields with a red asterisk (*) are required and must be completed before you can submit your application. Additional questions may become required based on your answers to a previous question.

Extracurricular Activities & Interests

1

Name*
BICYCLING
Start Year
2009
Start Month
May
End Year
2012
End Month
July
Approximate Weeks Per Year
6
Approximate Hours Per Week
40
Do you plan to participate in college?
Yes
Did you participate in grade 9?
Yes
Did you participate in grade 10?
Yes
Did you participate in grade 11?
Yes
Did you participate in grade 12?
Yes
Did you participate in a post-secondary grade?
Yes

2

Name*
BASKETBALL
Start Year
2010
Start Month
January
End Year
2012
End Month
June
Approximate Weeks Per Year
20
Approximate Hours Per Week
10
Do you plan to participate in college?
Yes
Did you participate in grade 9?
Yes
Did you participate in grade 10?
Yes
Did you participate in grade 11?
Yes
Did you participate in grade 12?
Yes
Did you participate in a post-secondary grade?
Yes

Work Experience

1

Title*
Cashier
Employer*
Subway
Are you currently employed with this organization?
Yes
From Month*
May
From Year*
2009
To Month
Please complete this field if you are currently NOT with this employer.
To Year
Please complete this field if you are currently NOT with this employer.
Hours Per Week*
25

SAT Test Scores

SAT Exam Taken?
Yes
Candidates for freshman admission: Indicate date when you took (or scheduled to take SAT and ACT)
SAT Test Date
10/1/2012
SAT Total Score
1600
SAT Critical Reading Best Score
800
SAT Writing Best Score
400
SAT Math Best Score
400

ACT Test Scores

ACT Exam Taken?
Yes
ACT Test Date
1/16/2012
ACT Composite Best Score
25
ACT Reading Best Score
25
ACT English Best Score
25
ACT Science Best Score
25
ACT Math Best Score
25
ACT Writing Best Score
25
TOEFL Exam Taken?
Yes
TOEFL Exam Date
10/3/2012
TOEFL Score
50
TWE Essay Score
16
Please enter your parents' information, even if they are deceased or no longer have legal responsibilities toward you. If you are a minor with a legal guardian (an individual or government entity), then please list that information below as well.

Household

Parents' Marital Status
Married

Parent

Relationship to you*
Mother
Is parent living?
Yes
Prefix
Dr.
First Name*
TestMom
Last Name*
Momtest
Parent 1 Suffix
D.D.S.
Home Phone
819 555-1212
Cell Phone
819 555-8888
Email Address
mymom@gmqil.com
Employer
Regis University
Occupation
None
Is parent address the same as your permanent address?
If your parent's address is the same as your permanent address, select Yes and skip this section; otherwise, fill out your parent's address.
No

Parent Address

Check if address is outside of U.S. or Canada
No
Address
1616 Haver Road
Address (cont)
apt 12
City
Denver
State/Province
Colorado
Zip/Postal Code
80221

Parent Education

Please enter your parent's educational information as it applies to them. If they have attended or are currently attending college, give the name of the institution and year the degree was earned if applicable. If they have received or are currently pursuing a graduate degree, give the name of the institution, degree earned or expected, and year the degree was earned if applicable.
Education
Bachelor
College
Howard University (5297)
Degree Year
2008
Graduate College
University of Alaska (4866)
Graduate Degree
Masters
Graduate Degree Year
2006

Other Parent

Relationship to you
Father
Is parent living?
Yes
Prefix
Dr.
First Name
My
Last Name
Daddy
Parent 2 Suffix
C.S.M.
Home Phone
999 555-1212
Cell Phone
999 555-1313
Email Address
mydaddy@gmilk.com
Employer
Self-Employed
Occupation
Doctor

Other Parent Address

Is parent address the same as your permanent address?
If your parent's address is the same as your permanent address, select Yes and skip this section; otherwise, fill out your parent's address.
No
Check if address is outside of U.S. or Canada
No
Address
999 Fred St
Address (cont)
Apt 1234
City
Baker
State/Province
California
Zip/Postal Code
59996

Other Parent Education

Please enter your parent's educational information as it applies to them. If they have attended or are currently attending college, give the name of the institution and year the degree was earned if applicable. If they have received or are currently pursuing a graduate degree, give the name of the institution, degree earned or expected, and year the degree was earned if applicable.
Education
Graduate
College
Hawkeye Community College (6288)
Degree Year
1966
Graduate College
Montana State University - Northern (4538)
Graduate Degree
Professional (MD,JD,etc)
Graduate Degree Year
1975

Legal Guardian

Legal Guardian Prefix
Dr.
Legal Guardian First Name
James
Legal Guardian Last Name
Guardian
Legal Guardian Suffix
C.F.P.
Legal Guardian Email Address
jguard@qmail.com
Legal Guardian Home Phone
676 555-8632
Legal Guardian Employer
Hardees
Legal Guardian Occupation
Owner

Legal Guardian Address

Legal guardian lives at same address?
No
Legal Guardian Address
589 Sawyer Way
Legal Guardian City
Ipsilanti
Legal Guardian State/Province
Michigan
Legal Guardian Zip/Postal Code
80211
Is legal guardian address outside of U.S. or Canada?
Yes
Legal Guardian Foreign Address Line
34356 Canada Way
Legal Guardian Country
Cocos (Keeling) Islands

Legal Guardian Education

Legal Guardian Education
Bachelor
Legal Guardian College
Georgia College & State University (5252)
Legal Guardian Degree Year
1976
Legal Guardian Graduate College
Loyola College in Maryland (5370)
Legal Guardian Graduate Degree
Doctoral

Siblings

Add Sibling
Yes

Sibling 1

First Name
Laney
Sibling 1 Age
21
Last Name
Jones
Relationship
Sister
Education
Associate
College
Calif St University Northridge (4707)
Degree Year
2005
Add Sibling
Yes

Sibling 2

First Name
Gil
Sibling 2 Age
44
Last Name
Testing
Relationship
Brother
Education
Bachelor
College
Duke University (5156)
Degree Year
1985
Add Sibling
Yes

Sibling 3

Relationship
Sister
Sibling 3 Age
19
First Name
Lisa
Last Name
Testing
Education
Doctorate
College
University of Alaska (4866)
Degree Year
1966
Please enter your information in each of the following sections. Fields with a red asterisk (*) are required and must be completed before you can submit your application. Additional questions may become required based on your answers to a previous question.

Personal Essay

Please include an essay that will allow the Admissions Committee to know you better. You may write on any topic you choose and the essay should not be lengthy (one page is best).
A 202-page account of the agency’s case against Armstrong included sworn testimony from 26 people, including nearly a dozen former teammates on Armstrong’s United States Postal Service and Discovery Channel squads who said they saw Armstrong doping to help him win every one of his record seven Tour de France titles. The file was the most extensive, groundbreaking layout of Armstrong’s alleged doping, bolstered by new interviews, financial statements and laboratory results. The agency said that witnesses’ testimony was so damning that it did not need any corroborating evidence to make its case, though its report included financial payments, e-mail messages, laboratory results and scientific data that the agency said proved Armstrong cheated by using banned performance-enhancing drugs and blood transfusions. “The U.S.P.S. Team doping conspiracy was professionally designed to groom and pressure athletes to use dangerous drugs, to evade detection, to ensure its secrecy and ultimately gain an unfair competitive advantage through superior doping practices,” the agency said. “A program organized by individuals who thought they were above the rules and who still play a major and active role in sport today.” Armstrong has repeatedly denied doping. Timothy J. Herman, one of Armstrong’s lawyers, said in an e-mail message that the 202-page report “will be a one-sided hatchet job — a taxpayer-funded tabloid piece rehashing old, disproved, unreliable allegations based largely on axe-grinders, serial perjurers, coerced testimony, sweetheart deals and threat-induced stories.”

Disciplinary History

Have you ever been convicted of a felony or misdemeanor?*
If so, you need to submit a mittimus report or arrest record.
Yes
Have you received disciplinary action since the 9th grade?*
Disciplinary action includes any probation, suspension, removal, dismissal, or expulsion as a result of any academic or behavioral misconduct.
No
Explain conviction or disciplinary action
If you have selected Yes for either question above, please give the approximate date of each incident, explain the circumstances, and reflect on what you learned from the experience.
Got into some trouble

Additional Information

Provide any additional information you would like us to know
I really want to go to Regis
Legacy
List any family members who have attended or are currently attending Regis.
Lisa Jones James Jones Mickey Mouse
Phi Theta Kappa
Yes
Are you being recruited to a varsity/NCAA II sport*
Yes
If so, which one?
Men's Cross Country

Certification

To the best of my knowledge, the information given in this application form is true. I understand that misrepresentation of facts on the application will be cause for refusal of admission, cancellation of admission, or suspension from Regis University. All documents pertaining to your application become the property of Regis University. By submitting this application, I agree to abide by the policies and regulations of the University.
Do you certify this statement?*
Yes
The electronic signature consists simply of your name, typed by you on your keyboard. The signature is your confirmation that the application you have filled out is your own work and the information is factually true. Once you type in your name and the date, this will count as your electronic signature.
Signature*
Test Signature
Signature Date*
10/11/2012

Additional Application Requirements


To complete your application file for review, the following documents must be submitted:

*Application and Personal Essay*
*Official High School/College Transcripts*
*Official Test Scores (Freshman Applicants)*
*Letter of Recommendation (Freshman Applicants)*

Regis University operates in accordance with applicable laws on equal opportunity and non-discrimination in the consideration of eligible students for admissions, scholarships, awards, and financial aid.