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Saturday, January 23, 2021
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First Name
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Last Name
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City
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State:
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ZIP Code:
Phone number including area code
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County (All Ohio and some Indiana counties are listed, everyone else should use "Other County" from the bottom of the list)
<Select>
OH-Adams
OH-Allen
OH-Ashland
OH-Ashtabula
OH-Athens
OH-Auglaize
OH-Belmont
OH-Brown
OH-Butler
OH-Carroll
OH-Champaign
OH-Clark
OH-Clermont
OH-Clinton
OH-Columbiana
OH-Coshocton
OH-Crawford
OH-Cuyahoga
OH-Darke
OH-Defiance
OH-Delaware
OH-Erie
OH-Fairfield
OH-Fayette
OH-Franklin
OH-Fulton
OH-Gallia
OH-Gequga
OH-Greene
OH-Guernsey
OH-Hamilton
OH-Hancock
OH-Hardin
OH-Harrison
OH-Henry
OH-Highland
OH-Hocking
OH-Holmes
OH-Huron
OH-Jackson
OH-Jefferson
OH-Knox
OH-Lake
OH-Lawrence
OH-Licking
OH-Logan
OH-Lorain
OH-Lucas
OH-Madison
OH-Mahoning
OH-Marion
OH-Medina
OH-Meigs
OH-Mercer
OH-Miami
OH-Monroe
OH-Montgomery
OH-Morgan
OH-Morrow
OH-Muskingum
OH-Noble
OH-Ottawa
OH-Paulding
OH-Perry
OH-Pickaway
OH-Pike
OH-Portage
OH-Preble
OH-Putnam
OH-Richland
OH-Ross
OH-Sandusky
OH-Scioto
OH-Seneca
OH-Shelby
OH-Stark
OH-Summit
OH-Trumbull
OH-Tuscarawas
OH-Union
OH-Van Vert
OH-Vinton
OH-Warren
OH-Washington
OH-Wayne
OH-Williams
OH-Wood
OH-Wyandot
IN-Adams
IN-Allen
IN-Blackford
IN-Clark
IN-Dearborn
IN-Decatur
IN-Delaware
IN-Fayette
IN-Franklin
IN-Henry
IN-Jay
IN-Jefferson
IN-Jennings
IN-Ohio
IN-Randolph
IN-Ripley
IN-Rush
IN-Scott
IN-Switzerland
IN-Union
IN-Washington
IN-Wayne
IN-Wells
Other County
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Actual or anticipated HS Grad or GED Year
<Select>
1950
1951
1952
1953
1954
1955
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1957
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1959
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2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
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What type of student will you be when you start at Clark State?
<Select>
Adult/Traditional - (no previous college)
Returning (Previous Clark State student)
Transferring credits in to complete a degree or certificate
Visiting (Taking a few classes to tranfer to another college)
High School Prospect
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Anticipated Entry Term
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Spring, 2021 (Begins February 15,2021)
Summer, 2021 (Begins June 01, 2021)
Fall, 2021 (Begins August 23, 2021)
If you are interested in extracurricular activities, indicate below.
1st Choice
<Select>
Campus Events
Men's Baseball
Men's Basketball
Student Senate
Theatre
Women's Basketball
Women's Softball
Women's Volleyball
2nd Choice
<Select>
Campus Events
Men's Baseball
Men's Basketball
Student Senate
Theatre
Women's Basketball
Women's Softball
Women's Volleyball
3rd Choice
<Select>
Campus Events
Men's Baseball
Men's Basketball
Student Senate
Theatre
Women's Basketball
Women's Softball
Women's Volleyball
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Date of Birth (mm/dd/yyyy)
January 2021
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Jan
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Primary Campus
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Beavercreek
Bellefontaine
Online
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