231600-Bevill State Community College-Fayette-UB-Application Form-Shaun

BEVILL STATE COMMUNITY COLLEGE

UPWARD BOUND-FAYETTE CAMPUS APPLICATION FOR ADMISSION
- Main Name
  
  First NameMiddle NameLast Name
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Home Phone No.
  (999)999-9999
- Student Cell No.
  (999)999-9999
- Age
- Birthdate
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearmm-dd-yyyy
- Gender
- Are you a citizen of the United States?
- If, “NO”: Permanent Resident I.D. Number
- Main Email
  example@example.com
- Father/Guardian
  
  First NameLast Name
- Employer/Occupation
- Work Phone Number
  (999)999-9999
- Email
  example@example.com
- Does this parent have a 4-year college degree?
- Mother/Guardian
  
  First NameLast Name
- Employer/Occupation
- Work Phone Number
  (999)999-9999
- Email
  example@example.com
- Does this parent have a 4-year college degree?
- Are you now receiving or have received services from another TRIO program? (ETS, Gear-Up)
- Is anyone else in your family receiving services from Upward Bound?
- If yes, who?
- INCOME DOCUMENTATION INFORMATION (Parent
- SELECT the number of people in your household.
- SELECT your annual taxable (not gross) family income for 2021.
- Does your child receive free or reduced lunch?
- Is the applicant a ward of the court
- If yes, provide Caseworker's Name
- If yes, provide Caseworker's Phone
- EDUCATION INFORMATION
- Select a high school
- Current Grade
- Current Cumulative GPA
- NEW FEDERAL CENSUS GUIDELINES
- Ethnicity: Check One
- Race: If not Latino, check one
- STUDENT & PARENT CONTRACT: In order for us to serve you with a strong academic, cultural, and collegiate program, we must have sincere commitment from you. Please carefully review the following:
  
  I understand that during my participation in Upward Bound:
  
  1. My goal will be to complete high school and pursue post-secondary education
  
  2. I will maintain at least a 2.50 GPA in high school
  
  3. I will participate in all required Upward Bound meetings, including Saturday seminars and trips, and every 6-week summer program on the Fayette campus
  
  4. I verify that I will have transportation to and from Upward Bound meetings.
  
  5. I will abide by all rules and regulations of Upward Bound and Bevill State Community College
  
  6. Poor attendance, lack of participation or failure to maintain GPA and grades will be a basis for probation and/or dismissal from Upward Bound
  
  In addition to the application data given here, we will need to obtain information from other sources to sufficiently meet the academic needs of our students and the reporting requirements of the U.S. Department of Education. We gather Information from high schools, colleges, testing institutions, and other agencies or universities on behalf of our students and program. Your signature at the bottom of this form authorizes Upward Bound to:
  
  1. Request a copy of your middle/high school and/or college transcripts and test scores from your school
  
  2. Request a copy of your SAT and/or ACT test scores
  
  3. Use your Social Security Number to request a copy of your financial aid application, transcripts, college enrollment status and awards from the federal & state funding agencies, post-secondary institutions, and National Student Clearinghouse
  
  4. Communicate with representatives from agencies, post-secondary institutions on your behalf
  
  I hereby authorize Upward Bound to contact and request information from, as well as to share information with, the above-mentioned parties. I give my son/daughter permission to participate in Upward Bound activities if accepted. Our signatures below indicate our commitment to the Upward Bound Student and Parent Contract.
  
  To the best of my knowledge, all the information I have provided in this application is true.
- Student's Name
  
  First NameLast Name
- Student’s Signature
- Parent’s Name
  
  First NameLast Name
- Parent's Signature
- Parent's Email
  example@example.com
- Please Check: I give permission for my son/daughter to be interviewed, photographed or videotaped by Upward Bound for use on radio, TV, in printed news media, or in program promotional materials and documentation
- STATEMENT OF CONFIDENTIALITY:
  
  The information in the application is confidential according to the Family Rights and Privacy Act. The U.S. Department of Education has the authority to gather the information requested in the application (20 USC 1231a). The only persons authorized to examine the contents of this application are the students, their parents, employees at the school attended, and the authorized Upward Bound staff.
- STUDENT INFORMATION
- Name
  
  First NameMiddle NameLast Name
- Social Security Number
  999-99-9999
- Date of Birth
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearmm-dd-yyyy
- Gender
- Age
- PERSONAL MEDICAL HISTORY
- Have you ever been diagnosed by a medical doctor with any of the following conditions
- Please list any surgeries you have had
- DISABILITIES
- Do you have any of the following disabilities?
- If vision, is it corrected?
- If learning disabilities, specify
- ALLERGIES
- Are you allergic to any serum, drug or medicine (penicillin, antitoxin, etc.?)
- If yes, specify
- Do you have any other allergies?
- If yes, specify
- MEDICATIONS
- Are you taking any maintenance medications or are you currently receiving other medical treatment
- If yes, specify
- IN CASE OF EMERGENCY
  
  Parent or Guardian Information
- Name
  
  First NameLast Name
- Home Telephone Number
  (999)999-9999
- Work Telephone Number
  (999)999-9999
- Place of work
- Emergency Contact (In case parent or guardian cannot be reached)
- Name
  
  First NameLast Name
- Telephone Number
  (999)999-9999
- Relation to you
- FAMILY PHYSICIAN
- Doctor's Name
  
  First NameLast Name
- Telephone
  (999)999-9999
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Preferred Emergency Center
- HEALTH INSURANCE
- Name of insurance company providing medical assistance
- Policy Number
- Expiration Date (if any)
- I hereby give my permission for my child {childName} to participate in all Bevill State Community College, Upward Bound activities, trips, and events. I further give my permission for my child to receive all necessary medical and/or psychological attention if the need arises; such need shall be at the discretion of the medical provider on duty and/or the Upward Bound employee supervision or coordinating the activity, trip, or event.
- Child Name
  
  First NameLast Name
- Signature of Parent or Guardian
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearmm-dd-yyyy

BEVILL STATE COMMUNITY COLLEGE