University Of Illinois-Urbana-Champaign-UB-Application Form

Office of Minority Students Affairs
Upward Bound College Prep Program
130 Turner Student Services; Suite 130
610 E John St; Champaign, IL 61820

Dear Applicant:

Thank you for your interest in joining the Upward Bound Program at the University of Illinois at Urbana-Champaign. TRIO Upward Bound is a federally funded program, providing FREE college access services to first-generation, low-income high school students. Since 1966, our Program has provided the tools, resources and training needed to help students be successful in high school and apply to college.

Students are eligible to apply if they meet the following requirements:
- Potential First-Generation college student
- Low-income (see the income chart on page 4)
- G.P.A 2.5 on a 4.0 scale
- Completed the 8th grade (may submit application in May of 8th grade year)
- Attending Central, Centennial or Urbana High School
Applications are accepted on a rolling basis. It is important that you complete your application as soon as possible, as there are a limited number of seats in the Program. When space is not available, an applicant will be referred to our waitlist for later consideration. Priority deadline for admission into the summer program is March 1st.

Be sure to complete the entire application. Incomplete application will not be processed. Prior to submission, please ensure the following required application materials are included to ensure prompt review.
- Signed Income Verification (page 4)
- Signed Release of Information Authorization Form (page 5)
- Copy of your most recent transcript/report card (you may email your grades to trioupwardbound@illinois.edu or upload them directly to the application)
Once your application is received, you will be notified of your application status. If you have any questions and/or do not receive an email within a week of submission, please contact our Office at 217-333-1889. We look forward to hearing from you!

Sincerely,

Ms. Sabrina Donegan

Assistant Director, Upward Bound

Mr. Domonic Cobb

Director, TRIO Programs

Privacy Statement: All information on this application will be held in strict confidence. This information is necessary to ensure that the applicant meets the criteria for admission to Upward Bound as established by the U.S. Department of Education. Information will only be shared with Upward Bound staff for reporting purposes to the U.S. Department of Education.

I. Student Information
Name*

First NameMiddle NameLast Name
Permanent/Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current/Local Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Email Address*
example@example.com
*You will receive confirmation of your application at this email address. This will be the primary address for contacting you during the application process. Emails to school accounts may not be received.
Home Phone*
(999)999-9999
Student Cell Phone*
(999)999-9999
Work Phone*
(999)999-9999
Date of Birth*

MonthDayYear
mm-dd-yyyy
Gender*
Are you Hispanic or Latino?*

YesNo
Race/Ethnicity (select all that apply)*

American Indian/AlaskanAsianHispanic or LatinoNative Hawaiian or Pacific IslanderBlack or African AmericanWhite or CaucasianOther

III. Interest Information
How did you learn about Upward Bound?
Have you ever applied to our program before?
Please select all Pre-College Access programs that you currently participate or have participated in

AVID (Advancement Via Individual Determination)Talent SearchPrincipal Scholars

IV. Citizenship
Are you a citizen of the United States?*

YesNo
Only if you answered No to the above question, please answer the following:
Are you a permanent resident of the United States?

YesNo
If applicable:
Permanent Resident #
Date Issued

MonthDayYear
mm-dd-yyyy
If you are not a permanent resident, are you in the U.S. for other than a temporary purpose with the intent of becoming a permanent resident?

YesNo
If you are in the process of becoming a permanent resident, please provide evidence from Immigration and Naturalization Service of your Intent to become a permanent resident.
Briefly provide any additional information, if necessary, regarding your family/living situation (ie. Homelessness, foster care, recent adoption). If you indicated guardianship above, please note whether this is a court-approved guardianship.

VI. Emergency Contact Information
This person will be contacted should a need for medical attention arise and the parent/legal guardian cannot be reached.
Name*

First NameMiddle InitialLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address*
example@example.com
Home Phone*
(999)999-9999
Cell Phone*
(999)999-9999
Relationship to you*

MotherFatherGuardianStep-ParentSisterBrotherOther
Does this individual live with you?*

YesNo

VIII. Parent/Guardian Certification
I declare that the information provided in this application is complete and accurate to the best of my knowledge. I understand that, if selected, my child will be expected to regularly attend all TRIO Upward Bound Program activities including Study Center/Academic Tutoring, High School Visits, and summer programs and participate fully throughout high school until he/she graduates and enrolls in a college or university. I understand that failure to fulfill the required commitment, my child can be terminated from the TRIO Upward Bound Program.
Name of Parent/Guardian*

First NameLast Name
Signature of Parent/Guardian*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Student Commitment Letter

I understand that TRIO Upward Bound requires students to adhere to the following expectations:
1. Students are expected to remain in Upward Bound through high school graduation.
2. Students are required to participate in both the six-week summer program and the academic year program.
3. Students are expected to follow the rules and regulations of TRIO Upward Bound and the University of Illinois at Urbana Champaign. Full copies of the Upward Bound rules and regulations are distributed at the start of the fall semester, spring semester and summer program, and are available upon request.
I have read and understand the required expectations for student participation.
Signature of Parent/Legal Guardian*

Clear
Signature of Student*

Clear
Date*

MonthDayYear
mm-dd-yyyy

VIII. Income Verification Form
Did your parent/guardian file taxes in the last year?*

YesNoUnknown
Do you currently receive or eligible to receive free/reduced lunch through your school?*

YesNoUnknown
How many people, including yourself, are in your family unit?*
(line 6d on Income Tax Form 1040 and 1040A)
Family annual taxable income (must use most recent tax information):*
Family annual taxable income (must use most recent tax information):
Per the chart below, does your family identify as low-income?*

YesNoUnknown

Federal TRIO Programs Current-Year Low Income Levels (If the applicant’s actual taxable income is less than the TRIO Program 2021 Annual Low-Income Level, then the applicant is considered a low income individual).

Size of Family Unit	48 Contiguous States, D.C. and Outlying Jurisdictions	Alaska	Hawaii
1	$19,320	$24,135	$22,230
2	$26,130	$32,655	$30,060
3	$32,940	$41,175	$37,890
4	$39,750	$49,695	$45,720
5	$46,560	$58,215	$53,550
6	$53,370	$66,735	$61,380
7	$60,180	$75,255	$69,210
8	$66,990	$83,775	$77,040

For family units with more than eight members, add the following amount for each additional family member: $6,810 for the 48 contiguous states, the District of Columbia, and outlying jurisdictions; $8,520 for Alaska; and $7,830 for Hawaii.

The term "low-income individual" means an individual whose family's taxable income for the preceding year did not exceed 150 percent of the poverty level amount.

The figures shown under family income represent amounts equal to 150 percent of the family income levels established by the Census Bureau for determining poverty status. The 2021 poverty guidelines are in effect as of January 13, 2021. Federal Register notice was published February 1, 2021

This statement confirms my family's income during the calendar year before my student applied for admission to the TRIO Upward Bound Program.

Parent Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy

IX. Releases of Student Information
Parent/Guardian Name*

First NameLast Name
Student Name*

First NameLast Name
Permission to Release Records

I, {parentguardianName}, the parent/guardian of {studentName} permit the release of my son/daughter academic records including but not limited to courses, grades, individual education plans, standardized test scores, and proof of graduation to TRIO Upward Bound Program at the University of Illinois at Urbana Champaign for the purposes of tracking student progress, and compiling and reporting data to the United States Department of Education. I understand that the United States Department of Education requires TRIO Upward Bound at Illinois to report on my child’s academic progress through their graduation from college or for at least six years after my child’s high school graduation.

I, {parentguardianName}, the parent/guardian of {studentName} permit TRIO Upward Bound to release of my educational records to my son/daughter respective high school and the U.S. Department of Education for the fulfillment of reporting requirements.

Media Release

I {parentguardianName}, the parent/guardian of {studentName} do hereby give my permission to TRIO Upward Bound at the University of Illinois at Urbana Champaign to photograph, film, videotape and/or make sound recordings of my child, to quote or publish statements of my child and to use such photographs, films, videotapes, sound recordings and/or other statements in Upward Bound or University educational and promotional/advertising materials and for other purposes specified below.

I understand that my child may be identified in any photographs, news stories or publications that Upward Bound considers appropriate for release to magazines, newspapers, University of Illinois and the Office of Minority Student Affairs web site, and/or other publications. I further understand that any such photographs, films, videotapes, sound recordings and/or written works are the property of TRIO Upward Bound at the University of Illinois and that neither my child nor I am entitled to any compensation for or rights in these materials.

I release TRIO Upward Bound and the University of Illinois from all liability with respect to the matters covered by this release.
Signature of Parent/Guardian*

Clear
Date*

MonthDayYear
Date
Signature of Student*

Clear
Date*

MonthDayYear
mm-dd-yyyy

X. Personal Statement
In 250 words or less, please respond to the following questions: What are your educational goals? What are your career plans and how do you plan to achieve them? Why do you wish to enroll in the Upward Bound Program?*
Please upload your grades*

Cancelof
Please upload your test scores*

Cancelof
Do you currently receive or eligible to receive free/reduced lunch through your school?

YesNoUnknown

Has your mother, father or guardian earned a Bachelor’s Degree?

	Yes	No	Unknown/NA
Father
Mother
Guardian/Other

One of the criteria for admission into the Upward Bound Program is meeting the income guidelines established by the Department of Education. Before we can determine your eligibility, please answer the following questions and attach a copy of your federal income tax return or appropriate documentation, which reflects your income.
1. Total number of exemptions claimed on the last federal income tax return or total number in the household
2. Taxable income (IRS form 1040, 1040A or 1040ez)

Federal TRIO Programs Current-Year Low Income Levels (If the applicant’s actual taxable income is less than the TRIO Program 2020 Annual Low Income Level, then the applicant is considered a low income individual).

PERSONS IN FAMILY/HOUSEHOLD	POVERTY GUIDELINE
For families/households with more than 8 persons, add $4,540 for each additional person.
1	$12,880
2	$17,420
3	$21,960
4	$26,500
5	$31,040
6	$35,580
7	$40,120
8	$44,660

This information is strictly confidential and will be maintained in the Upward Bound office ONLY. The General Education Provision Act (Private Rights of Parents and Students) or more generally known as the Buckley Amendment, offers parents the option of sending their financial information under a separate cover (i.e. this page may be detached and sent separately from the student’s application) and such information shall be confidential and not available to the student.

Low-income eligible (refer to the chart below)

YesNo
Please upload your tax form here

Cancelof