Student Information Form

Jason Coates

Education Consultant, College Counselor and Student Coaching
Student Information Form

There are only 6 required questions on this form, which will allow me to contact you to schedule an information session. However, please provide as much info here as possible so I can get back to you with the best strategy to start your college plan. I am looking forward to hearing from you.
Student Name*

First NameLast Name
Student Mobile*

Country codePhone Number
Student Email*
example@example.com
Date of Birth*

MonthDayYear
Current School Attending

High school or secondary school
Name of School
Grade in School
current year
Current GPA
unweighted point average (if known)
Date of secondary school graduation*
month and year
College Start Date*
Term and Year (Fall2026), if known. Put ? if unknown.
Parent Information
Parent 1 Name

First NameLast Name
Parent 1 mobile #
Parent 1 email
example@example.com
Parent 2 Name

First NameLast Name
Parent 2 mobile #
Parent 2 email
Address

Street Address

Street Address Line 2

City

Postal Code
Most Recent Academic Grades

Letter Grades or Number Grades
English Grade
Math Grade
Science Grade
2nd Language Grade
Social Studies / History Grade
Other Grades
indicate subject(s) and grade
Other Grades
indicate subject(s) and grade
Extracurricular Activities

how do you spend time outside the classroom? List significant clubs, sports, etc. activities by year.
Grade 9 Activities
Grade 10 Activities
Grade 11 Activities
Grade 12 Activities
Honors and/or Awards Received

have you been recognized? List significant awards or honors by year.
Grade 9 Awards/Honors
Grade 10 Awards/Honors
Grade 11 Awards/Honors
Grade 12 Awards/Honors
Testing Information

Insert PSAT / SAT or Pre-ACT/ ACT scores (if known)
SAT Score (Reading)
indicate date taken or planned
SAT Score (Math)
indicate date taken or planned
ACT Composite Score
indicate date taken or planned
College Planning Goals
List the specific College and/or University names that you are interested in.
What is your intended area of study/major?
List the geographical areas or specific US states of interest (Northeast, South, West Coast, etc)
Preferred College Size

Small (less than 5000 students)medium (5000-10,000 students)large (10,000+ students)
Preferred College Setting

Urban / City (200,000+ pop)Suburban (25,000-200,000 pol)Rural (25,000 pop)
What are your education goals for the next year?
How would you define success in working with a college/education consultant?
Should be Empty:

Jason Coates

Student Information Form

Current School Attending

Parent Information

Most Recent Academic Grades

Extracurricular Activities

Honors and/or Awards Received

Testing Information

College Planning Goals