Virginia Polytechnic Institute-Southwest-UB-Application Form

  • UPWARD BOUND PROGRAM PARTICIPANT APPLICATION

  • We are here to help! If you have any questions about the application, please contact us at upwardbound@vt.edu or 540-231-6173

    • GENERAL INFORMATION 

    • GENERAL INFORMATION

    • What is your gender?

    • What is your Ethnicity?
    • What is your Race? (check all that apply)
    • Date of Birth
       - -
    • Check one:
    • Check one:
    • Grade
    • GPA
    • Have you successfully completed algebra or pre-algebra?
    • If yes, in which grade did you successfully complete algebra or pre-algebra?
    • Do you have a job outside of school?
    • If yes, how many hours per week do you work?

    • Parent 1 Information

    • Check one:
    • What is the highest level of education completed? Check all that apply

    • Parent 2 Information

    • Check one:
    • What is the highest level of education completed? Check all that apply
    • With whom do you currently reside?

    • ELIGIBILITY PROFILE 

    • ELIGIBILITY PROFILE

      Please select all of the choices that apply to you and your family: 

    • Citizenship Status
    • My first language is English
    • I am currently pursuing a(n):
    • Select if applicable:
    • After high school, I plan to:
    • Do you live in any of the following situations apart from your parents, or with no financial support from them? (Please check all that apply)
    • Are you an orphan or a ward of the court?
    • Are you involved in the criminal justice system?
    • Do you currently participate in a TRIO or “TRIO like” program sponsored by another college or university? (Upward Bound, Talent Search (TS) or GEAR UP)?
    • How did you hear about Upward Bound?

    • INCOME VERIFICATION AFFIDAVIT 

    • INCOME VERIFICATION AFFIDAVIT

    • INCOME VERIFICATION
    • If your family did not pay income taxes last year, indicate the source(s) of the non- taxable income below: (Check all that apply)

    • Has your taxable income substantially changed in the past year?
    • CONSENT AND RELEASE 

    • CONSENT AND RELEASE

    • PARENT PERMISSION
      I give permission for my child/student to attend the Virginia Tech TRIO Programs and all the required activities including field trips.

    • MEDICAL AND LIABILITY RELEASE
      I authorize the TRIO Programs staff to act on my behalf in case of an emergency, accident or illness. I release Virginia Tech, and the Virginia Tech TRIO Programs staff from any liability or claims that might occur due to the participation of my child in the program.

    • MEDICAL AND LIABILITY RELEASE
      I authorize the TRIO Programs staff to act on my behalf in case of an emergency, accident or illness. I release Virginia Tech, and the Virginia Tech TRIO Programs staff from any liability or claims that might occur due to the participation of my child in the program.

    • RECORDS RELEASE
      I understand that my initials on this application permits Virginia Tech and the
      Virginia Tech TRIO Programs to collect and use all academic and extracurricular
      activity information on my child during high school and college. This information gathered includes but it is not limited to academic progress reports, academic transcripts, standardized testing by school, local, state or federal programs and other performance reports. All of the information gathered will be kept secure and be confidential. Also, the gathered information will be utilized to develop better services for the benefit of each participant and their specific needs.

    • PHOTO AND VIDEO RELEASE
      For valuable consideration received, the undersigned hereby irrevocably consents to and authorizes the use by Virginia Polytechnic Institute and State University ("Virginia Tech") of the undersigned's name, image, voice and/or likeness as follows: Virginia Tech shall have the right to publish, re-publish, adapt, exhibit, perform, reproduce, edit, modify, make derivative works, distribute, display or otherwise use or re-use the undersigned's name, image, voice and/or likeness in connection with any product or service in all markets, media or technology now known or hereafter developed in perpetuity throughout the universe including advertising, promoting and merchandising the product or service. Virginia Tech may exercise any of these rights itself or through any successors, transferees, licensees, distributors or other parties, commercial or nonprofit.

    • STUDENT AND PARENT SIGNATURE 

    • STUDENT AND PARENT SIGNATURE

      In accordance with the Privacy Act of 1974 (Public Law No. 93.579, 5 U. S.C. 552A), you are hereby notified that the Department of Education is authorized to collect information to implement the TRIO Programs program under Title IV of the Higher Education Act of 1965, as amended (Pub. Law 102-325,sec. 402C). In accordance with this authority, the Department receives and maintains personal information on participants in the TRIO Programs. The principal purpose for collecting this information is to administer the program, including tracking and evaluation participants’ academic progress. Providing the information on this form, including Social Security number (SSN), is voluntary; failure to disclose a SSN will not result in denial of any right, benefit, or privilege to which the participant is entitled. The information that is collected on this form will be retained in the program files and may be released to other Department officials in the performance of official duties. I understand that the TRIO Programs staff will use the data provided with this application to assess my/my child’s eligibility, in accordance with federal regulations. I specifically grant permission to Virginia Tech TRIO Programs to obtain information from the school system regarding my child’s academic and disciplinary record. TRIO Programs Staff may obtain any and all information and documentation necessary for processing my/my child’s application and for meeting federal performance and tracking reporting requirements, including but not limited to transcripts, grade reports, and test scores. I certify that any information which I have provided herein is true and correct to the best of my knowledge.

    • Clear
    • Date
       - -
    • Clear
    • Date
       - -
    • Submit 
    • Should be Empty: