Upward Bound Program Application

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Salem University Upward Bound

Email *

Today's Date *

YYYY

High School *

Student ID Number (WVEIS) *

Name (Last, First, Middle) *

Preferred Name

Address (Include City, State, Zip) *

Phone Number (Parent) *

Phone Number (Student)

Social Security Number (Last 4 digits only) *

Race/Ethnicity *

Date of Birth *

YYYY

Place of Birth *

Are you a US Citizen? (If no, state legal status) *

Current grade in school *

Are you currently on an IEP or 504 plan? *

Yes

Do you currently live with your biological parent(s)? *

Yes

If not, who do you live with? (Their relationship to you)

Do you plan to attend a college or university after graduation?

Yes

Maybe

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