Please check ONE box only:
          

Personal Information:

FIRST NAME: 
MIDDLE NAME: 
LAST NAME:        
HOME ADDRESS:
CITY:
STATE:     ZIP:
HOME PHONE NUMBER: 
CELL PHONE NUMBER: 
PARENT/GUARDIAN'S FULL NAME:  
PARENT/GUARDIAN'S WORK NUMBER:  
EMAIL ADDRESS:   
CITIZENSHIP: Are you a US citizen or US permanent resident?     
GENDER:
OPTIONAL:  Please check all that apply:
African/American, Black                    
West Indian
 American Indian, Native American, Alaskian Native
                tribal affiliation
                enrollment number
Asian/Asian American
Hispanic or Latino
White
Other (please specify) 

School Information:
High School Name 
High School City and State  
Year of Graduation  

Cumulative GPA (Please note weighted GPA only if available)

   out of       point scale

Rank (Please note weighted rank only if available)

   out of       number of students in the senior class

Family Information:
Mother's Occupation 
Mother's College (if any)   
Mother's Degree 
Mother's Other Degrees 

Father's Occupation

Father's College (if any)   
Father's Degree 
Father's Other Degrees 

Testing/Education Information:
Please note only the highest score.
SAT I                 
              date taken            verbal         math          writing 
ACT         
            date taken        composite
If you haven't take the SAT or ACT tests please list PSAT or ACT Plan scores below.

PSAT      
             verbal           math 

PLAN  
             composite
List Senior Program if not included on your transcript:

Additional Information:  

Airport/Train Station closest to your home
Have you visited the Wesleyan University campus in the past two years?
If yes, month/year   No
How were you informed about this Travel Program:
Visiting Dean College Fair Another Student
Other 
Academic Opportunity Program affiliation (e.g. A Better Chance, Upward Bound, Venture Scholars, Jack and Jill, etc.)

How did you learn about the Transportation Assistance Program?

Personal Statement:
In a few paragraphs, discuss your interest in visiting Wesleyan University and why you should be considered for this program.