Fort Valley State University-UB-2025 Application Form

UPWARD BOUND PROGRAM
Fort Valley State University
STUDENT APPLICATION PACKET
Upward Bound is a program funded by the U.S. Department of Education. The purpose of Upward Bound is to identify, recruit, and select high school students with academic potential who meet federal eligibility guidelines. The Upward Bound Program will enhance academic achievement in high school and prepare participants to enter post-secondary education (Universities, Colleges, Vocational/Technical Schools).

Upward Bound participants attend academic enrichment workshops, educational field trips, social activities, tour various colleges and universities, and receive academic support through tutors, faculty and staff.

Upward Bound students must successfully complete one six-week summer residential session on the FVSU campus to be eligible for continuation in the program. The summer program simulates a college environment at no cost for the student. The summer includes hands-on interactive enrichment classes that include math, science, English, foreign language, and other exciting elective courses. Students also participate in social enrichment activities, career readiness field trips, open dialogues and debates, using AI to assist with student learning and support, wellness and fitness activities, and a host of other exciting activities.

What may a student expect to gain from being in the Upward Bound Program?
- Preparation for college, including information on how to obtain financial aid, how to be admitted to college, tips on test taking, and preparation for standardized and college entrance tests
- Improvement in grades
- The opportunity to make friends and connections with others from area high schools
- Academic and career counseling
- Field trips and social enrichment activities
- Guidance in making decisions on educational goals
All Upward Bound Services are FREE for participants.

For questions or additional information, please contact us at:

Upward Bound Program
Fort Valley State University
Attention: Mrs. Christian Holt
1005 State University Drive, Fort Valley, GA 31030
Phone: 1- 478-825-6965
Email: holtc@fvsu.edu
STUDENT APPLICATION
Application Instructions

To apply for the TRIO Upward Bound Program at Fort Valley State University, please complete all required components listed below and submit all materials by the designated deadline. Applications missing required documents will be considered incomplete.
Application Checklist
ONE school counselor recommendation is required.

Please copy and share the link with a school counselor and request them to fill out the recommendation form for you.

Counselor Recommendation Form https://botform.compansol.com/253444910900856
Counselor Name

First NameLast Name
Counselor Email
example@example.com
ONE math or science teacher recommendation is required.

Please copy and share the link with a teacher and request them to fill out the recommendation form for you. (Include the links for the new bot forms for the teacher and counselor recommendation form). Please use same font as used in this section on on the application.

Teacher Recommendation Form https://botform.compansol.com/253513333620851
Teacher Name

First NameLast Name
Teacher Email
example@example.com
Confidentiality of Information

The personal information provided to the Upward Bound Program is required by the U.S. Department of Education and is protected under the Federal Education Rights and Privacy Act (FERPA). This information is used solely for evaluation purposes and to verify student eligibility for program participation. Access to these records is limited to authorized Upward Bound staff or individuals specifically designated to determine eligibility. Information or records related to individual students or groups will not be disclosed to any person, agency, or organization without written consent from the student, parent, or legal guardian. To ensure compliance with these confidentiality guidelines, applicants must sign, and date all required Authorization of Information and Release forms.
- Student Information
- Student Name:
  
  First NameLast Name
- Preferred Name (if different):
- Date of Birth:
  
  MonthDayYear
  mm-dd-yyyy
- Gender:
- Ethnicity:
- Social Security #
  999-99-9999
- Are you a U.S. citizen?
- Primary language spoken at home:
- Home Address:
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Student Email:
  example@example.com
- Student Cell Phone:
  (999)999-9999
- Who do you live with?
  
  Other
- High School:
- Current grade level:
- Do you currently have a job?
- If yes, where do you work and how many hours per week?
- Do either of your parents have a 4-year college degree?
- Mother/Guardian:
- Father/Guardian:
- Educational Informs
- What high school do you attend?
- What is your educational plan after high school?
- What course of study are you currently enrolled in at your high school?
- Have you ever been sent to the office for any reason?
- If yes, please explain:
- What type of post-secondary school are you considering?
  
  Other
- What college majors are you considering?
- Are you currently enrolled in another federally funded TRIO program (Educational Talent Search, GEAR Up etc.)? (If chosen to participate in Fort Valley State University’s Upward Bound Program, the student will discontinue participation in any other federally funded program to avoid duplication of services.)
- If yes, which one?
- List all extracurricular activities you are currently involved in (sports, clubs, church, employment, etc.):
- Will you be able to participate in the six-week residential summer session?
- Are you involved in any activity that may prevent regular participation on some Saturdays during the school year?
- If yes, please explain:
- Do you know anyone enrolled in the Upward Bound Program?
- If yes, who?
- T-shirt size:
- What do you usually do in your spare time or on weekends?
- In which areas do you need help from the Upward Bound Program? (check all that apply)
- Answer the following questions in 3–5 sentences each.
- 1. Why are you interested in joining the Upward Bound Program?
- 2. What are your academic and career goals after high school?
- 3. What challenges have you faced in school, and how do you hope Upward Bound can help you?
- Student Signature:
- Date:
  
  MonthDayYear
  mm-dd-yyyy
- Parent / Guardian Information
- Primary Parent/Guardian (1)
- Name:
  
  First NameLast Name
- Relationship to student:
- Address (if different from student):
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Cell Phone:
  (999)999-9999
- Work Phone:
  (999)999-9999
- Email:
  example@example.com
- Employer:
- Did this parent/guardian complete a 4-year college degree?
- Primary Parent/Guardian (2)
- Name:
  
  First NameLast Name
- Relationship to student:
- Address (if different from student):
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Cell Phone:
  (999)999-9999
- Work Phone:
  (999)999-9999
- Email:
  example@example.com
- Employer:
- Did this parent/guardian complete a 4-year college degree?
- Relative (not living in household) to contact in case of emergency:
- Name:
  
  First NameLast Name
- Relationship:
- Phone Number:
  (999)999-9999
- Certification:
  
  “I certify that the information listed above, including any financial information, is accurate and true to the best of my knowledge.”
- Parent/Guardian Signature:
- Date:
  
  MonthDayYear
  mm-dd-yyyy
- Medical Information
- Student Name:
  
  First NameLast Name
- Emergency Contact Name:
  
  First NameLast Name
- Emergency Contact Phone:
  (999)999-9999
- Rate the student’s overall health:
- Are there any conditions that would interfere with your child’s schoolwork or participation in sports/physical activities?
- If yes, explain:
- Does the student have any health conditions the staff needs to be aware of?
- If yes, list them:
- Is the student currently under a doctor’s care or taking prescription medication(s)?
- If yes, list medications:
- Does the student have any allergies (food, medications, insect bites, etc.)?
- If yes, explain:
- Does the student have any dietary preferences (e.g., vegetarian, vegan, etc.)?
- If yes, explain:
- Are there medical procedures or treatments you do not consent to?
- If yes, explain:
- Income / Financial Information
- How many people live in your home?
- Source(s) of income (check all that apply):
  
  Other
- What is your taxable income amount? (this can be found on your 1040 or 1040A tax form)
- What income tax form did you file this year?
- Select your taxable income range (this can be found on your 1040 or 1040 A tax form)
- (Attach/Upload most recent federal tax return: 1040, 1040A, 1040EZ, or verification from a government agency such as SNAP, Social Security, unemployment, etc.)
  
  Cancelof
- I HEREBY AFFIRM THAT ALL FINANCIAL AND EDUCATIONAL INFORMATION LISTED IN THIS APPLICATION IS TRUE AND CORRECT. I UNDERSTAND THAT THIS INFORMATION IS BEING GIVEN IN CONNECTION WITH THE RECEIPT OF FEDERAL FUNDS, THAT INSTITUTION OFFICIALS MAY VERIFY INFORMATION AND THAT DELIBERATE MISREPRESENTATION MAY SUBJECT ME TO PROSECUTION UNDER APPLICABLE STATE AND FEDERAL STATUTES.
- Parent/Guardian Signature:
- Date:
  
  MonthDayYear
  mm-dd-yyyy
- Program Waiver
- Release and waiver of liability
  
  “I understand that some academic and recreational activities in Upward Bound involve an inherent risk of physical injury. By signing below, I release Fort Valley State University, the Board of Regents of the University System of Georgia, and Upward Bound staff from claims for injury or damages arising out of my child’s participation in program-related activities, including but not limited to intramural and recreational activities, and field trips.”
- Student Name:
  
  First NameLast Name
- Parent/Guardian Name:
  
  First NameLast Name
- Parent/Guardian Signature:
- Date:
  
  MonthDayYear
  mm-dd-yyyy
- Medical authorization
  
  “In the event of serious illness or accident, every effort will be made to contact the parent/guardian. If a delay in treatment could be harmful, I authorize Fort Valley State University Upward Bound staff to secure medical services from a licensed physician and local hospital or clinic as needed. I understand I am financially responsible for costs that exceed the amount covered by program insurance.”
- Parent/Guardian Signature:
- Date:
  
  MonthDayYear
  mm-dd-yyyy
- Consent for release of academic records
  
  “I hereby give permission to the Fort Valley State University TRIO Upward Bound Program to obtain any and all of my secondary and post-secondary academic records, including school transcripts, test scores, teacher evaluations, class schedules, and financial aid documents (such as FAFSA and scholarship award letters). These records will be used only for program participation, selection, academic evaluation, and to meet U.S. Department of Education reporting requirements. This includes future college transcripts, admission applications, class schedules and financial aid documents (such as the FAFSA, student aid reports and scholarship award letters. I understand that these records are confidential and will only be used internally for program participation, selection and academic evaluation. I also understand that compiled records may be used exclusively to meet the U.S. Department of Education regulations and program evaluation. None of my identified, individual records will be released to any person, corporation, or organization without further written consent.
- Student Signature:
- Date:
  
  MonthDayYear
  mm-dd-yyyy
- Parent/Guardian Signature:
- Date:
  
  MonthDayYear
  mm-dd-yyyy

STUDENT APPLICATION

Student Information

Educational Informs

Parent / Guardian Information

Medical Information

Income / Financial Information

Program Waiver