Name(Required) First Name Middle Initial Last Name Phone(Required)Phone Type(Required)HomeOfficeCellSocial Security Number(Required) Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemaleOtherAddress(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County(Required) Email Address(Required) Current High School(Required) Graduation Year Ethnicity(Required) African American American Indian or Alaskan Native Asian White Native Hawaiian or Other Pacific Islander Are you Hispanic/Latino?(Required) Yes No Parent / Guardian Name(Required) First Last Relationship(Required) Mother Father Grandparent Guardian Parent / Guardian Phone Number(Required)Parent / Guardian Email Address(Required) Enter Email Confirm Email Are you a first generation college student (your parent(s)/guardian(s) did not attend college)?(Required) Yes No Do you have a family member who attended or graduated from Bluefield State University?(Required) Yes No Relationship Year GraduatedSemester(Required) Fall Semester (August-November) Spring Semester (January-April) Do you with to participate on a pathway for any of the following programs?(Required) Yes No If on a pathway, please check one of the following: Criminal Justice Education Grow Your Own Health Professions (i.e. Nursing, Rad Tech, Sonography) Social Sciences STEM (Science, Technology, Engineering, Mathematics) Course(s) in which you wish to enroll(Required)DisclosuresBy providing your cellular telephone number, you agree to receive text-based communication from Bluefield State University, the West Virginia High Education Policy Commission, and College for West Virginia (CFWV). Your information will not be shared with institutions other than those to which you have shown interest, nor will your information be shared with or sold to vendors or other third-party agencies. Standard text-messaging rates may apply, and you are responsible for any costs incurred while receiving texts. You may opt-out at any time by replying with the word, “STOP.”Signature(Required) TweetShareShare
