Bowdoin College-UB 2-Eligibilty Form

BOWDOIN UPWARD BOUND ELIGIBILITY ASSESSMENT FORM
All fields marked with * are required and must be filled.
This form should be completed by the parent(s) or guardian(s) of the student who is
applying to Upward Bound.
All information is confidential and is required to determine eligibility for UB.
If you have any questions, please contact our office at 1-877-879-2731.
Student*

First NameMiddle Init.Last Name
Email*
example@example.com
Name of parent/guardian completing this form*

First NameLast Name
Parent/Guardianʼs Home Phone #*
(999)999-9999
Parent/Guardianʼs Cell #*
(999)999-9999
Parent/Guardian E-Mail Address *
example@example.com
Is this student a Ward of the Court?*

YesNo
(If YES, skip to the end of form, sign and provide case manager contact with release.)
Did either of the studentʼs biological or adoptive parents complete a bachelorʼs or a 4-year college degree?*

Yes, MotherYes, FatherNeither biological (or adoptive) parent completed a 4-year degree
Name of College/University (Mother)
Year
Name of College/University (Father)
Year
How many individuals live in the same household? Please include the student,parents, guardians or other relatives or dependents living in the home.*
What is the TAXABLE INCOME listed on parent/guardian?s 2023 federal income tax return (line 15 on Form 1040)?*
2023 Form 1040-on line 15
OR

Parent/guardian was not required to file federal income tax return in 2023 and does not have taxable income to report.
Is the student a citizen of the United States?*

YesNo
If not a citizen, is the student a lawful permanent resident of the United States?

YesNo
If yes, please provide documentation of permanent residency.

Cancelof
If neither a citizen nor permanent resident, please describe your immigration status:
I CERTIFY THAT THE INFORMATION REPORTED ON THIS ELIGIBLITY STATEMENT IS, TO THE BEST OF MY KNOWLEDGE AND BELIEF, TRUE, CORRECT, AND COMPLETE.
Parent/Guardian Signature*

Clear
Relationship to the Student*
Date*

MonthDayYear
Date

Academic Records Release
Student Name*

First NameLast Name
Student’s High School:*
Expected Graduation (month/year):*
Upward Bound at Bowdoin College works collaboratively with high school personnel as we assist students in graduating from high school and preparing for success in college. The school will be asked to provide academic information during the Bowdoin Upward Bound selection process and if accepted, for the remainder of high school.
Student Signature*

Clear
Date*

MonthDayYear
Date
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
I/We the undersigned,

1. Permit the release of the following student records for the above-named student as part of the application to Upward Bound and, if accepted, continuously for the remainder of high school:
- Academic Transcript & current grades
- NWEA/Map Growth Assessments
- PSAT Scores
- SAT Test Scores/SAT Subject Test Scores
- Relevant IEP and/or 504 plans
- Any other pertinent academic informatio
- Disciplinary history
2. Permit high school administrators, student services staff and teachers to discuss the student’s academic progress and disciplinary history with Upward Bound staff.

3. Permit Upward Bound to share information with the school and community agencies which will contribute to my child’s success.

This academic records release expires 6 years from the high school graduation date above, in accordance with the terms of the federal Upward Bound grant, even if the student withdraws from the Upward Bound program.
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Parent Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy

MEDIA RELEASE
I authorize the use of my name and photographs for print & social media (including the Upward Bound yearbook, website, brochures, posters and news articles) as they relate to Upward Bound events & information.
Student Intitials*
Parent Initials*
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Parent Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
I authorize any college to which I apply to provide Financial Aid (FA) information
(including package details & status) to Bowdoin College Upward Bound staff. I authorize Upward Bound staff to discuss my FA award with college FA administration where I have applied.
Student Initials*
Parent Initials*

COLLEGE TRANSCRIPT & TRACKING RELEASE
Upward Bound is required by the US Department of Education to track college enrollment & progress of all participants for six years beyond high school. If selected, I authorize the release of all of my college enrollment, major and degree completion information to Bowdoin UB form secure third parties such as National Student Clearinghouse for tracking purposes.
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Parent Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Student Initials*
Parent Initials*
I authorize my high school to provide the following to Upward Bound at the time of
application: guidance recommendation, complete transcript with attendance and test
scores, immunization and health information from school nurse and, if applicable an
IEP or 504 plan. I selected for UB, I authorize the release of test scores, grades, academic progress and attendance to UB on an ongoing basis via the school's electronic system of grades or through the guidance office
Student Initials*
Parent Initials*

Parent/Guardian Input
How do you feel about your studentʼs potential participation in the Upward Bound program?
Participation in Upward Bound includes several overnight trips and extended stays on campus (up to 3 weeks) for students following sophomore and junior year of high school. How will your student and other family members handle these absences from home?

Please share how you feel your student is doing in the following areas:

	Area of growth	This is improving	Doing pretty well	This is a strength
Time management
Homework completion
Asking for help
School attendance
Organization
Using strategies to calm down when upset

What do you feel are your studentʼs particular strengths?
In what areas do you think your student could use additional support or guidance?
What are your thoughts on your studentʼs current academic and/or career plans?
Is there anything else that would be helpful for us to know about your student or your family situation?
Bowdoin College Upward Bound is 100% funded through a grant from the US Department of Education in the amount of $ 309,505.

Bowdoin College complies with applicable provisions of federal and state laws that prohibit discrimination in employment, admission or access to its educational or extracurricular programs, activities, or facilities based on race, color, ethnicity, national origin, religion, sex, sexual orientation, gender identity and/or expression, age, marital status, place of birth, veteran status or against qualiﬁed individuals with disabilities on the basis of disability.

BOWDOIN UPWARD BOUND ELIGIBILITY ASSESSMENT FORM