Fillable UPWARD BOUND PROGRAM - VIRGINIA STATE UNIVERSITY www.vsu.edu/upwardbound (Virginia State University)

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UPWARD BOUND PROGRAM - VIRGINIA STATE UNIVERSITY www.vsu.edu/upwardbound (Virginia State University)

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  • 30 check-boxes
  • 97 other fields

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File type: PDF

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APPLICATION_FOR_THE_UPWARD_BOUND_PROGRAM_2014
UPWARD BOUND PROGRAM - VIRGINIA STATE UNIVERSITY
#3 JACKSON PLACE, BOX 9014 – VIRGINA STATE UNIVERSITY, VA 23806
(804) 524-5811 (Office) - - - (804) 524-5142 (Fax)
www.vsu.edu/upwardbound
APPLICATION
Applicant’s Name:
Last First Middle Initial
School: Grade Level:
Current Grade Point Average:
Social Security #: / / Today’s Date:
Date of Birth:
BEFORE COMPLETING THIS APPLICATION, PLEASE READ THE FOLLOWING:
• Upward Bound students must be a citizen or national of the United States.
• Upward Bound students at the time of initial selection must be a first generation college student or low income individual.
• Upward Bound students must have a need for academic support in order to pursue a program of education beyond high
school.
• Upward Bound students must live on the campus of Virginia State University for the five (5) or six (6) weeks summer session
and must attend Saturday classes with regularity during the academic year program (September - May).
• Upward Bound students will be expected to participate in all cultural activities and trips included in the Upward Bound
Program.
• Upward Bound participants must adhere to all rules, regulations, and guidelines outlined in the Upward Bound Student
Handbook.
Please use a blue or black pen or a typewriter to complete this application.
Office Use Only:
Date Received:
Counselor Information & Recommendation Form Essay Verification of Income (Tax Form)
Teacher Recommendation (1) Teacher Recommendation (2) Transcript (Grade Test Scores)
Approved by:__________________________________________ Disapproved:________________________________
APPLICATION_FOR_THE_UPWARD_BOUND_PROGRAM_2014
Name:
Last First Middle Initial
Permanent Home Address:
Street (Apt. #) City State Zip Code County
Home Phone Number: ( ) Social Security #: / /
Are you a U.S. Citizen? Yes No Will you require a Form 120 to obtain a Visa? Yes
No
Your current mailing address (if different from your permanent home address):
Street Address Apt. # City State Zip Code County
Sex:
Male Female Birth Date:_____________________________________
Month Date Year
*If your parent(s) or guardian(s) have separate addresses please check (√) the box to the left of the name, to indicate that
you wish information sent to that parent or guardian. You may check both boxes and information will be sent to both. If
no box is checked, information will be sent to parent or guardian Number 1 unless we are otherwise instructed:
Parent or Guardian No 1 : Relationship
Last First MI
Home Address(if different from yours):
Street City State Zip
Home Phone Number:( ) Work Phone Number:( )
Occupation: Place of Employment:
Parent or Guardian No 2 : Relationship
Last First MI
Home Address(if different from yours):
Street City State Zip
Home Phone Number:( ) Work Phone Number:( )
Occupation: Place of Employment:
Has either of your parent(s) or guardian(s) completed a four (4) year college?
Yes No
If yes, please check relationship?
Mother Father Guardian
The following information is requested so that we may demonstrate to the U.S. Department of
Education, this institutions compliance with Title VI of the 1964 Civil Rights Act. (Voluntary)
African American Native American Hispanic American Caucasian American
Asian American Bi-Racial American Other American International
How many sisters do you have? Older? Younger? At home?
How many brothers do you have? Older? Younger? At home?
APPLICATION_FOR_THE_UPWARD_BOUND_PROGRAM_2014
List school activities and organizations:
What subject(s) in your curriculum do you need assistance or improving?
What subject(s) in your curriculum do you like least?
How would you rate yourself as a student?
Excellent Good Average Poor
Name at least two (2) teachers who know you very well:
TEACHER’S NAME SCHOOL
TEACHER’S NAME SCHOOL
Name at least two (2) persons in your community who know you very well:
NAME ADDRESS/PHONE#
NAME ADDRESS/PHONE#
What are your special interest(s) or hobbies?
Will you need any special assistance? Yes No
If yes, please specify:
APPLICATION_FOR_THE_UPWARD_BOUND_PROGRAM_2014
UPWARD BOUND PROGRAM FAMILY FINANCIAL DATA
The Family Financial Data Form must be completed by the parents or guardian of the student who wishes
to enter Upward Bound. All income must be reported in order to have an accurate statement regarding
the financial status of the family. (
A Federal Tax Return Form MUST BE included in this packet)
Name of Student SSN: / /
Last First Middle
Address
Street City State Zip Code
Telephone Number: ( )
Student resides with: Both Parents Father Only Mother Only Guardian
Name of Parent(s)/Guardian(s)
Address
Street City State Zip Code
INCOME:
Father: $ Mother: $ Guardian: $
(Before Taxes) (Before Taxes) (Before Taxes)
Do you (parent/guardian) receive public assistance?
Yes No If yes, how much per month?
Welfare $ Social Security $ Retirement $ Other (specify) $
Did you file a federal income tax form?
Yes No
What was the total adjusted gross income shown on last year's federal income tax return? $ _
Submit a recent copy of your Federal Income Tax Return or a letter from Social Services/Social
Security regarding income. This is necessary in order to document income at the time of entry.
The application will be delayed if this information is not submitted.
List all dependents living in your household:
Name(s)
Age
Relationship
We hereby acknowledge that the information submitted herewith is true and correct. Our signatures
below also indicate that we are not four year college graduates.
Signature of Father Date
Signature(Parent or Guardian)Mother Date
NOTE:
The Application Will Not Be Processed Without All Requested Information
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UPWARD BOUND PROGRAM - VIRGINIA STATE UNIVERSITY www.vsu.eduupwardbound (Virginia State University)

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Completed 1 September 2020

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