Undergraduate Admissions

Student Ambassador Application

Student Information

Name: Banner ID:
Campus/Local Address:
Campus/Local Phone:

Cell Phone:
(including Area Code)

Email Address:

Semester applying for:  

How did you learn about this position?


Background Information

Student Status:           Anticipated Graduation Date:
Hometown (including State):
I entered Brockport as a    If transfer, from which college:
Something fun/interesting/unique about you:
Most unique experience at Brockport:
Favorite food at Brockport:
Favorite place to study:
Favorite campus event:
Favorite way to stay active on campus:
Favorite off-campus event/location:
One class every student should take before graduating from Brockport:
Five important things that every freshman should bring to campus:


Please indicate the times below that you are available during the week. You must be available for the entire time frame (or close to the entire time frame).
Monday 10:45 - 11:45 am   Monday 12:45 - 2:15 pm
Tuesday 10:45 - 11:45 am   Tuesday 12:45 - 2:15 pm
Thursday 10:45 - 11:45 am   Thursday 12:45 - 2:15 pm
Friday 10:45 - 11:45 am   Friday 12:45 - 2:15 pm

Academic Information

Major(s):     Minor/Certification:

Are you a member of Delta College?   

Are you a member of the Honors Program?

Have you participated in Study Abroad?   

If yes, where?

Honors/Awards/Scholarships Received:

Additional Information

Have you ever been documented within the residence halls?

* Being documented does not disqualify an applicant from consideration.

* If you answered yes, please describe the situation, including what actions were taken and how the matter was resolved:

Name of your RD:     Name of your RA:
**After you submit this application, you MUST ALSO email a resume OR a PDF version of your myBrockport Co-Curricular Transcript to Jenny Rae Siplo (jrsiplo@brockport.edu). **




Please contact Jenny Rae Siplo by phone at (585) 395-2751 or by e-mail at jrsiplo@brockport.edu.