Southeastern Louisiana University

Request for Application

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Request for Application

Personal Information
Fields marked with an * are required.

First Name:*

Middle Initial:*

Last Name:*

Date of Birth:*

Please indicate your gender* Male Female

Email: *

Address:*

City:*

State:*

Zip Code:*

Telephone #:*

Please indicate the best time to reach you by phone* Day of Week:

Time:

AM or PM?:

Ethnicity (race):

US Citizen?* Yes No
If not, please indicate your citizenship:

Physical Condition*

Do you have any physical condition or handicap which requires special medical treatment, diet, travel arrangement, or other consideration?

Yes No
If yes, explain:

Have you previously attended this program?* Yes No
If yes, when?

Contact Person

(someone who will always know how to contact you, not at the same address)

Name:

Phone #:

Address:

City:

State:

Zip Code:

Family Information

With whom do you live with? Both Parents Mother Father
Relative, Specify:
Other, Specify:

Mother's Name:

Mother's Work Number:

Mother's Other Number:

Mother/Step-Mother Educational Level: (highest attained)

Father's Name:

Father's Work Number:

Father's Other Number:

Father/Step-Father Educational Level: (highest attained)

Legal Guardian's Name:

Legal Guardian's Work Number:

Legal Guardian's Other Number:

Legal Guardian's Educational Level: (highest attained)

Number of Children Living at Home:

Number of People Living in the House: (including yourself)

Scholastic Information

Current Grade:

Grade Point Average:

ACT Score:

Year of Graduation:

High School:

School Address:

School City:

School State:

School Zip Code:

School Phone:

School Counselor's Name:

School Counselor's Phone:

Type of School:

Training Interest After High School:

4-Year College	2-Year College
VoTech	Armed Forces
Training School	None

Career Interests:

Do you participate in one of the following TRIO programs?

Math Science Upward Bound	Talent Search
EOC	none
Other:

If so, with what University or Organization is your program affiliated?

Program Director:

Program Counselor:

Email for Program:

Mailing Address for Program:

Phone Number for Program:

Upward Bound Program

Staff

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