West Hills College-Lemoore-VUB

Veterans Upward Bound Application

This application must be completed to be considered for participation in the Veterans Upward Bound program. The personal info you provide to the program is confidential and is protected by the Family Educational Rights and Privacy Act (FERPA). No one will see the information unless they work with or for Veterans Upward Bound or are specifically authorized to see the information.

The following documents are required for determining eligibility and should be submitted with the application:

1. DD214 Discharge Papers (member 4)

Contact Information
Name *

First Name Last Name
Birth Date *

Month Day Year
mm-dd-yyyy
Last 4 Digits of Social Security Number *
XXX-XX-9999
Street Address *

Street Address

Street Address Line 2

City State

Zip Code
Primary Phone Number *
(999)999-9999
Cell Number *
(999)999-9999
Would you like to receive text messages? *

Yes No
Email Address *
example@example.com

First Generation Status
Do either of your parents have a Bachelor's degree? *

Yes No
If yes, were you under 18 years of age and living with your parents?

Yes No

Goals
What are your educational goals? *
What are your employment goals? *
How did you learn about Veterans Upward Bound? *

West Hills College Lemoore website Educational Institution Word of mouth Advertisement Community Agency Veterans Agency Social Media

Agreement and Signature
I would like to participate in the Veterans Upward Bound (VUB) program and receive the free services provided. I grant permission to West Hills College Lemoore to request enrollment and/or degree verification from any post- secondary level institution that I am attending or will attend in the future. I also understand that VUB may also provide my information to WHCL.

As a program funded by the U.S. Department of Education, VUB is required to collect certain information about all participants and track my progress, as well as submit an annual report on the program's status, including its participants, to the Department of Education. I hereby grant my permission to VUB to use my name and/or picture for the purpose of promoting VUB in any media formats now existing or created in the future.

When using the Veterans Upward Bound computers and facilities, program participants will abide by the Students’ Rights and Responsibilities outlined in the West Hills College Lemoore Catalog (https://www.westhillscollege.com/lemoore/catalog/current/student-rights-and-responsibilities/#Code-ofConduct)

By submitting this application/pre-survey, I affirm that the information is true and correct to the best of my knowledge. Completion of this application indicates my desire to participate and receive services and for program staff to obtain and utilize my personal information to assist me in reaching my educational goals.
Name *

First Name Last Name
Signature *

Clear
Date *

Month Day Year
mm-dd-yyyy