Western Kentucky University

* I am applying to be a part of ISEC as a:

First year student

Second year student (sophomore)

Third year student (junior)

Fourth year and beyond (senior)

* First Name

* Last Name

* WKU Student I.D. Number (801-XX-XXXX)

* Date of Birth (mm/dd/yr)

* High School (City and State)- ex: Topper High School, Bowling Green, KY

Race / Ethnicity (Check all that apply)

Asian / Pacific Islander

Black / African American

Hispanic / Latino

Native American / Alaskan Native

White (Non-Hispanic)

Two or More Races

* I identify as:

Male

Female

Other

FIRST-GENERATION COLLEGE STUDENT

First-generation is defined as one of the following: A) an individual whose natural or adoptive parents did not receive a bachelor’s degree; B) an individual who, prior to the age of 18, regularly, resided with and received support from only one parent and whose supporting parent did not receive a bachelor’s degree; C) an individual who, prior to the age of 18, did not regularly reside with or receive support from a natural or an adoptive parent.

Are you a first-generation college student?

Yes

* Cell Phone (xxx-xxx-xxxx)

* Email (WKU student email preferred)

I understand that by typing my full name below, I acknowledge that the information provided will be used to consider eligibility for participation in the ISEC CAReS program, and I certify under penalty of perjury that this information is true, complete, and accurate to the best of my knowledge.

* Write full name to confirm understanding of the above statement.

Yes