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Dartmouth College
admissions.dartmouth.edu
Office of Admissions | 6016 McNutt Hall | Hanover, NH 03755
Phone: 603.646.2875 | Fax: 603.646.1216
[email protected]
2015 Summer Courses Application
Please complete this form and mail it as soon as you decide to apply to Dartmouth for the summer term session. All other material
can be submitted separately from this form. The deadline for all summer term applications is May 8, 2015.
A non-refundable application fee of $85.00 in U.S. currency is required of all candidates. A check or money order should be
made payable to Dartmouth College and should be attached to the bottom of this page.
All materials can be sent to:
Summer Admissions, Admissions Office, 6016 McNutt Hall, Dartmouth College, Hanover, NH 03755-3541
Personal Information
Full Legal Name:
Last
First
Preferred Name:
Middle
Date of Birth:
Sex:  Male  Female
Month
Home Address
Street Address
City
Current Address (If different from home address)
Street Address
Suffix (Jr., III, etc.)
Day
State
Year
Zip Code
Country
Dates at address From:
City
State
Email Address:
Zip Code
To:
Country
Phone Number:
Disciplinary History
Have you ever been found responsible for a disciplinary violation at any educational institution you have attended from the 9th grade
(or the international equivalent) forward, whether related to academic misconduct or behavioral misconduct, that resulted in disciplinary action?  Yes  No
Have you ever been adjudicated guilty or convicted of a misdemeanor, felony, or other crime?  Yes
 No
Have you ever received an Other Than Honorable Discharge, Bad Conduct Discharge, or Dishonorable Discharge from any branch of
the military? (if applicable)  Yes  No
If you chose yes to any of the disciplinary questions, please explain on a separate sheet of paper and attach to the application.
Demographics (optional)
Marital Status  Never Married  Married  Divorced/Separated Number of Children _______ Ages: _____________
Place of Birth: ________________________________________________
U.S. Citizenship status:
If not a U.S. Citizen, country of citizenship:
First Language:
Language spoken at home:
Which of the following groups do you identify with? Multiple selections are welcome.
Are you of Hispanic, Latino or Spanish origin?
 Yes
 No
 Asian American or Asian : ___________________________  Black or African American __________________________
 American Indian or Alaska Native : ____________________  Native Hawaiian or other Pacific Islander _______________
Are you enrolled?
 Yes
 No
 White, Caucasian or Middle Eastern ___________________
Household Information
Parent Relationship 1:  Mother  Father
 Guardian/Other:
Marital Status:  Never Married  Married  Divorced/Separated  Deceased (Year)_________
Parent 1’s Full Name:
College, if any:
Parent 1’s Address:
Parent 1’s Occupation & Employer:
Parent Relationship 2:  Mother  Father  Guardian/Other:
Marital Status:  Never Married  Married  Divorced/Separated  Deceased (Year)_________
Parent 2’s Full Name:
College, if any:
Parent 2’s Address:
Parent 2’s Occupation & Employer:
Siblings
Name, Age, Institution Attended
Name, Age, Institution Attended
Educational Information
CEEB Number:
Current College/University:
College/University Address:
City
State
Undergraduate year you will have completed by June 2015
Country
 Freshman  Sophomore  Junior
Current Academic Major (if known):
Other Schools Attended Since Ninth Grade
Name of School
CEEB Number
Location
Dates of Attendance
Month/year to month/year
to
to
to
to
Please indicate your best results to date on any of the following examinations:
SAT I: Best Critical Reading __________ Best Math ________ Best Writing ________ ACT : Best composite score ________
TOEFL: Best Total Score ____________  iBT  CBT  PBT
SAT II Subject Tests:
Advanced Placement :
Subject______________________ Score _______
Subject______________________ Score _______
Subject______________________ Score _______
Subject______________________ Score _______
Subject______________________ Score _______
Subject______________________ Score _______
Please list, in order of importance, those college pursuits which best represent your principal interests outside of the
classroom. These pursuits may include special interests and talents, extracurricular activities, employment, community
involvement, leadership positions, and any related honors or distinctions.
Activity
Years Participated
Approximate
Hours/Weeks/Years
Positions Held or
Honors Won
 Fresh  Soph
 Junior  Senior
 Fresh  Soph
 Junior  Senior
 Fresh  Soph
 Junior  Senior
 Fresh  Soph
 Junior  Senior
Using the space provided, please describe your reasons for seeking to spend a summer term at Dartmouth College.
You may also include any other information that you would like the Admissions Committee to know about yourself
in this space. Feel free to attach additional sheets if necessary.
Required Signature
I certify that all information submitted in the admissions process-including the application and supporting documents,
is my own work, factually true, and honestly presented. These documents will become the property of Dartmouth
College and will not be returned to me. I understand that I may be subject to a range of possible disciplinary actions,
including admission revocation, expulsion, or revocation of course credit and grades, should the information I have
certified be false. I acknowledge that I have reviewed the application instructions .
I affirm that I have included the non-refundable application fee of $85 in the form of a check or money order, made
payable to Dartmouth College.
Signature:
Date: