SIUE TRIO Upward Bound Program

Prospective Student Biographical Information

Prospective Student First Name *

Prospective Student Last Name *

Prospective Student Email Address *

Prospective Student Mobile Phone Number*

Prospective Student Birthdate

Prospective Student Mailing Address *

Country

Street

City

Region

Postal Code

Prospective Student Information

Anticipated Student Type *

Primary Mode of Classes *

Face to Face

Online Degree (limited degree options; no athletic or extracurricular opportunities)

Anticipated Start Year *

Anticipated Start Term *

Anticipated Major *

Which secondary education specialty are you interested in? *

Other Comments

How many guests will be joining you for the event?

Do you or a family member require any physical assistance (ie. wheelchair accessibility)? Please provide details, as you feel comfortable.

Yes

No

If applicable please identify the person who influenced you to visit Greenville University

Do you have any other specific questions, comments, or concerns you would like us to be aware of? If so please outline them below.

I agree to grant Greenville University and its authorized representative's permission to record on photography film and/or video, pictures of my participation. I further agree that any or all of the material photographed may be used, in any form, as part of any future publications, brochure, or other printed materials used to promote Greenville University, and further that such use shall be without payment of fees, royalties, special credit or other compensation. *

Yes

No

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SIUE TRIO Upward Bound Program