Wayne State University-VUB

Veterans Upward Bound – Client Application

Please submit a copy of your DD214 and picture ID with this application

As a grant recipient of the US Department of Education, Veterans Upward Bound (VUB) is committed to the guidelines provided under The Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. § 1232g; 34 CFR Part 99) which is a Federal law that protects the privacy of student education records. Veterans Upward Bound will not disclose your personal identifiable information to any third-party without your prior written consent.

Education Information
(Not eligible if you have received a bachelors’ degree.)
High School Grade Level

HS Drop-outHS GraduateGED/HS EquivalencyHS Graduate w/ some collegeGED/HS Equiv. w/ some collegeUnknown
Highest Grade Completed
High School
Last Year Attended
Post-Secondary Education (PSE)
Have you ever attended a college or university?

YesNo
Last college attended:
State
Start Date

MonthDayYear
mm-dd-yyyy
End Date

MonthDayYear
mm-dd-yyyy
Do you have any degrees, certificates or credits earned?
Year Earned:
What are your PSE goals and objectives?

Student Contract
As a VUB/VEOP client and student you are expected to: regularly attend the classes that have been scheduled for you, meet with your counselor for timely counseling and advising, and abide by the other regulations, as set forth by this office and explained by our staff. I commit myself to academic progress. I further agree to be counseled concerning my client/student responsibilities while I participate in the above program.
Client/Student Photograph Release Statement (Optional)
I hereby give my permission to the Veterans Upward Bound program to photograph, audio - and/or video tape, and/or interview me, and release such materials for the purposes of publication and/or promotion of VUB program. (This may include such events as class sessions, veterans’ day, graduation, open house, and others.) You may Opt out at any time I agree;

YesNo
Client/Student Text Message (Optional)
I hereby give my written consent for Wayne State University Veterans Upward Bound to contact me regarding our educational programs and services using email, telephone or text – including our use of automated technology for periodic texts to the wireless number you provide. You may opt out at any time. I agree;

YesNo
I certify that the information on this form is true and accurate to the best of my knowledge. I also grant Veterans Upward Bound permission to obtain and review any academic documents needed to complete the application process and that is pertinent to my participation in the program. This may include certification of my prior and/or current school/college attendance.
Clients/Student's Signature

Clear
Date Signed

MonthDayYear
mm-dd-yyyy
Counselor Signature

Clear
Date Signed

MonthDayYear
mm-dd-yyyy

Authorization for Release of School Records
I hereby, authorize the Veterans Upward Bound/VEOP at Wayne State University to obtain any records or data from my Secondary and/or post- secondary education files that is pertinent to my participation in the program. This may include certification or my prior education and/ or current school/ college attendance. (This information may be used to determine scholarship eligibility, provide statistical data, and for other VUB purposes.)
Clients/Student's Signature

Clear
Date Signed

MonthDayYear
mm-dd-yyyy

Additional Necessary Documents
Please upload copies of the following documents (DD214 and Picture ID required):
Copy of your DD214:

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Picture ID:

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Proof of Income for Last Year:

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