Your E-mail Address:

Student Last Name

Student First Name

Student Middle Initial

Participation Status
New 2017-2018
Continuing
Re-Entry
Prior Year

Parent/Student Permanent Contact Information

House Number & Street Name

City

State

Zip Code

Home Phone (please include area code)

Cell Phone (please include aread code)

Student/School Year Contact Information

Street

City

State

Zip Code

Home/Dorm Phone

Cell Phone

Current School Information

Grade
9th Grade
10th Grade
11th Grade
12th Grade
Enrolled in a program of post-secondary education
Other
Not Applicable (Not enrolled in high school or post-secondary school.)

School Name

Counselor Name (if in High School)

UBMS Participation Information

Last Year of UBMS Participation: (ex: Fall 2016 or Summer 2017)

Participation Level for the 2016-17 Reporting Year
Academic & Summer
Academic & Bridge
Academic only
Summer only
Summer Bridge Only
Prior Year (Limited services)
PriorYear (No Services)

For High School Students Only

What is your expected high school graduation date? (MM/DD/CCYY)

Anticipated College

Anticipated Major

Is Wichita State University one of your Top Five choices?
Yes
No

For High School Graduates Only

Are you currently attending a Post-Secondary School? (ex: College, Trade School)
Yes
No
If YES, What is the name of the college or university you are currently attending?

If NO, Do you anticipate attending next semester?
Yes
No

Grade Level
Accepted but not enrolled yet
1st year, never attended before
1st Year, attended before
2nd Year, Sophomore (30+ hours completed)
3rd Year, Junior (60+ hours completer)
4th Year, Senior (90+ hours completer)
Graduate

School Type
Career
Vo-Tech
2 Year Private
2 Year Public
4 Year Private
4 Year Public