APPLY TO RANDOLPH

NOTE: You will need to complete this form within 30 minutes of starting it or the page will time out and the submit button at the bottom will not work. We recommend printing it out, and then typing up the answers that require text input. Then you can cut and paste the information into the form rather than trying to complete it in 30 minutes.

PERSONAL/ACADEMIC INFORMATION

Proposed Year of Enrollment:

2024 2025

Proposed Term of Enrollment:

Fall
Summer
Winter
Spring

I am applying as:

Lynchburg community member

Randolph College faculty/staff member

High school student/dually enrolled (Attending during school hours; high school transcript and letter from principal required)

High school student/not dually enrolled (High school transcript required)

CVCC Co-Enrolled Student

Visiting student - current student at: (Select an institution using the tools below.)

US Students - Search by your institution's ZIP code:

Intl Students - Search by country:

Can't find your institution? Enter the full name here:

* Legal First Name:

Middle Name/Initial:

* Legal Last Name:

Nickname (Preferred Name):

* Birth Date (mm/dd/yyyy):

Legal Gender:

Female Male

Gender Identity:

Pronoun:

* Street Address or PO Box:

Address Line 2:

* City:

State/Province:

Zip/Postal Code:

Country:

Home Phone:

Cell Phone:

* Email:

* Your Graduating/Attending High School:

Select a high school using the tools to the right.

US Students - Search by your High School's ZIP code:

Intl Students - Search by country:

Homeschool Students -

Can't find your school? Enter the full name here:

Your Graduation Year:

Have you been enrolled at RC before?

Yes No

If yes, please list date(s):

RESIDENCY INFORMATION

Are you a U.S. citizen or permanent resident:

Yes No

If not, of what country are you a citizen:

Social Security Number
(Required or submit Substitute Form W-9S)

If you are a US permanent resident or green card holder, please give us your alien registration number:

WE ARE REQUIRED TO ASK THE FOLLOWING FOR US GOVERNMENT REPORTING PURPOSES:

Ethnicity:

Hispanic/Latino
Not Hispanic/Latino

Race (select one or more):

American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

DEPENDENT STUDENTS MUST PROVIDE PARENT/GUARDIAN'S NAME AND ADDRESS BELOW:

With whom do you make your permanent home:

Guardian Type:

Guardian's First Name:

Guardian's Last Name:

Guardian's Address:

Guardian's City:

Guardian's State/Province:

Guardian's Country:

Guardian's Zip/Postal Code:

Guardian's Email:

Guardian's Home Phone:

Guardian's Cell Phone:

REQUIRED STATEMENT OF INTEREST

Please indicate which course(s) you are interested in taking:

Please indicate why you are interested in enrolling in course work at Randolph College:

How will this opportunity help with your future goals:

* Verification:

By submitting this form I am indicating that the above information is complete, factually correct and honestly represented. In addition, it indicates that if accepted to Randolph College I will uphold the standards of the following Honor Pledge:

I pledge absolute honesty in my academic work and in all personal relationships at Randolph College. I will maintain the integrity of my word and I will respect the rights of others. Realizing that these standards are an integral part of life at Randolph College, I assume my obligation to uphold this honor pledge. If at any time I fail to live up to my obligation of this pledge, I will report myself to the Chair of the Judiciary Committee. I will also ask others to report themselves for any infraction of this pledge.