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 TRIO Upward Bound Program at the University of Illinois at Urbana-Champaign. TRIO Upward Bound is a federally funded by the Department of Education to prepare high school students for academic success from high school to college. Through a variety of free services, participants are provided the tools, resources and skills needed to support student success.

You may apply as early as the Spring Semester of your 8th grade year. All applicants should meet one or all of the following requirements:
- Attend (or will attend) one of following high schools
  - Centennial High School
  - Central High School
  - Urbana High School
- Maintain citizenship, permanent residency, or are in the process of becoming a permanent resident of the United States
- Meet federal guidelines based on income
- First-generation (neither natural or adoptive parents has obtain a baccalaureate degree)
- Current GPA of 2.5 or above
Applications are accepted on a rolling basis and reviewed once the application is complete. 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 applications is March 1st.

In addition to fully completing the application, please ensure the following documents accompany your application materials to ensure prompt review.
- Signed copy of parent’s 1040, 1040A, or 1040EZ Income Tax Return for the most recent year
- Test Scores (i.e. PARCC, PSAT)
- Copy of your most recent transcript/report card
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

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 Name Middle Name Last Name
Permanent/Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Current/Local Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
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
Cell Phone *
(999)999-9999
Work Phone *
(999)999-9999
Date of Birth *

Month Day Year
mm-dd-yyyy
Gender *
Are you Hispanic or Latino? *

Yes No
Ethnicity (select all that apply) *

American Indian/Alaskan Asian Native Hawaiian or Pacific Islander Black or African American White or Caucasian Other

II. Academic Information
Current Year in School *

8 9 10 11
Name of Current/Future High School *

Centennial High School Central High School Urbana High School
Expected Month/Year of Graduation *
mm-yyyy
Guidance Counselor Name *

First Name Last Name
Guidance Counselor Email *
example@example.com
Have you been suspended or had other disciplinary issues? *

Yes No
If yes, please explain. *

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

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

Yes No
If applicable:
Permanent Resident #
Date Issued

Month Day Year
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?

Yes No
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.

IV. Family Background
Do you currently receive or eligible to receive free/reduced lunch through your school?

Yes No Unknown

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

Yes

Unknown/NA

Father

Mother

Guardian/Other

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.
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)
Low-income eligible (refer to the chart below)

Yes No

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).

Size of Family Unit	48 Contiguous States, D.C. and Outlying Jurisdictions	Alaska	Hawaii
1	$19,140	$23,925	$22,020
2	$25,860	$32,325	$29,745
3	$32,580	$40,725	$37,470
4	$39,300	$49,125	$45,195
5	$46,020	$57,525	$52,920
6	$52,740	$65,925	$60,645
7	$59,460	$74,325	$68,370
8	$66,180	$82,725	$76,095

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.

Parent/Guardian Signature

Clear
Please upload your tax form here

Cancel of

V. Parent/Legal Guardian Information
Name *

First Name Middle Initial Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email Address *
example@example.com
Home Phone *
(999)999-9999
Cell Phone *
(999)999-9999
Parent/Guardian Type *

Mother Father Guardian Other
Degree(s), if any
Employer *
Work Phone *
(999)999-9999
Name

First Name Middle Initial Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email Address
example@example.com
Home Phone
(999)999-9999
Cell Phone
(999)999-9999
Parent/Guardian Type

Mother Father Guardian Step-Parent Other
Degree(s), if any
Employer
Work Phone
(999)999-9999

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 Name Middle Initial Last Name
Address

Street Address

Street Address Line 2

City State / Province

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

Mother Father Guardian Step-Parent Sister Brother Other

VII. 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 Search Operation Hope Principal Scholars 4-H Extension

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 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 Upward Bound Program.
Name of Parent/Guardian *

First Name Last Name
Signature of Parent/Guardian *

Clear
Date *

Month Day Year
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 *

Month Day Year
mm-dd-yyyy

IX. 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? *

Releases of Student Information
Parent/Guardian Name

First Name Last Name
Student Name

First Name Last 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 *

Month Day Year
Date
Signature of Student *

Clear
Date *

Month Day Year
mm-dd-yyyy
Please upload your grades *

Cancel of
Please upload your test scores *

Cancel of