STUDENT INFORMATION

In addition to an application, we ask every student to have a teacher submit a recommendation for them. Below you will enter the name and email address of a teacher who knows you well and is able to tell the Upward Bound staff a little more about you! The teacher will be sent a form to fill out and submit back to Upward Bound staff.

STUDENT ELIGIBILITY FORM

Please ask your parent/guardian to complete this student eligibility form. Please feel free to reach out to the Upward Bound staff at upwardbound@etsu.edu or 423 439-5619 if you have questions.  

If yes, you do not need to fill out the rest of this page. Please continue to the Student Information portion of the application.

I. Family Income Information

If you filed income taxes in 2023, please complete the following and submit a copy of your 2023 tax form with this application. The information we need is your family’s TAXABLE INCOME, not your annual total income. Taxable income is smaller than total income. Taxable income is the amount on your tax returns after all adjustments, exemptions, and deductions have been subtracted. This amounts appears on line 15 on the 1040 form. Please look at your 2023 tax form before completing the following:

IF YOU DID NOT FILE INCOME TAX FORMS IN 2023 please complete the following:

II. First Generation Eligibility

Educational status of natural/adoptive parents (check all that apply):

 

Parent/Guardian 1:

Parent/Guardian 2:

STUDENT INFORMATION FORM

UPWARD BOUND ACTIVITIES

The ETSU Upward Bound program hosts up to 10 evening meetings at ETSU for all of our students. These activities include:

1) Weekly School Visits – Each week staff members from the ETSU Upward Bound program visit our fourteen target high schools to speak with our students. Many of our visits occur during the students’ lunch periods allowing them to meet with us without missing class. These visits typically take 5 – 10 minutes in which they receive our Community Scoop – a weekly newsletter with information about the program and upcoming dates. The Upward Bound staff also discusses with our students their academic successes and needs. These weekly check-ins are the primary way we communicate information to our students; thus, consistent attendance is critical.

2) Monday Night Sessions – One Monday per month the ETSU Upward Bound program hosts an evening meeting at ETSU for all of our students. Transportation will be provided from the area high schools to/from ETSU, and students will be served dinner at ETSU. Students attend seminar classes, guest speaker lectures, and workshops during these sessions.

3) Summer Residential Program – Every summer our students are invited to live on the ETSU campus for a five-week residential program. Students will be on campus Sunday evenings through Friday afternoons taking various academic and enrichment classes to help prepare them for their next year of high school. Upward Bound will not be providing transportation to/from the area high schools to ETSU during the summer component. Students will be living in residential halls on campus with Upward Bound staff and will be supervised while on campus. Students who successfully complete the summer program will have the opportunity to attend our summer trip. All of these activities (including summer trip transportation, food, housing, and admission tickets) are provided at no cost to the students or their families.

The ETSU Upward Bound program believes that students who actively participate in these activities will enhance themselves academically and ultimately better prepare themselves for college success. While we recognize and desire for students to participate in a wide range of activities in their schools and communities, participation in the above mentioned activities are required for students to remain in the program. The ETSU Upward Bound program, within reason, will try to accommodate students’ unique situations that may prevent them from full participation in every event (for example, there have been numerous students who check out early during the summer residential program to attend practice for athletics, band, and other activities). 

Information Release

I hereby authorize all officials to release my high school and college transcripts, TCAP scores, Gateway scores, EOC scores, and any other pertinent schools records and test scores to the ETSU Upward Bound program. I understand that Upward Bound will track my post-secondary participation in accordance with grant requirements. I understand and agree that all information furnished in this application is correct to the best of my knowledge and that all information will be kept confidential.

Parental Consent and Release

During the Program, students may participate in dangerous and/or hazardous activities. I expressly assume all risks involved with my Child participating in these activities. Minors may be unsupervised at certain times during the Program. Program activities include attending college preparatory academic classes, attending enrichment/elective activity classes, attending off-campus cultural / educational activities, participating in job shadowing and internship opportunities, living in a residence hall, participating in small group/large group activities and participating in recreational activities.

Release. I agree to release, waive, indemnify, and forever discharge the University, its agents, employees, officers, and trustees from any and all claims or liability for injury or damages (including loss or damage to property) arising from or attributable to my child's participation in or travel associated with the Program, unless it is due to the willful fault or gross negligence on the part of the University.

Photo/Video. I hereby authorize the University and those acting pursuant to its authority to record my child's likeness and voice in any medium; use my child's name in connection with these recordings; and use, reproduce, exhibit, or distribute in any medium these recordings for any purpose that the University deems appropriate, including promotional or advertising efforts.

USDA Non-Discrimination Statement

The ETSU Upward Bound program participates in the USDA (United States Department of Agriculture) Summer Food Service Program. If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter by mail to U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, DC 20250-9410 or by fax (202) 690-7442 or by email at program.intake@usda.gov

Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339 or (800) 845-6136 (Spanish).

USDA is an equal opportunity provider and employer.

Parent and Student Signature:

I certify that the education and financial information that I am submitting in this application is accurate.

I certify that I agree to the above Information Release, Parental Consent and Release, and USDA NonDiscrimination Statement provided in this application packet.

By signing below, the student agrees to participate in the various Upward Bound activities mentioned in the application packet. Furthermore, the parent/guardian signature below states that you (parent/guardian) support your student participating in the various activities offered by the ETSU Upward Bound program. (If you have any questions about any activities, please do not hesitate to call the office at 423-439-5619.)