Virginia Union University-UB-Application Form

Virginia Union University ~ Upward Bound Program
NEW STUDENT APPLICATION

For questions or additional information, please contact:
Dr. NC Garris-Watson, Director
Brenda Yancey, Counselor
1500 North Lombardy Street - Baptist Memorial Building, 2nd Floor – Richmond, VA 23220
804.257.5884 (office)
Website: www.vuu.edu/upwardbound ~ Email: upwardbound@vuu.edu
Please check the following boxes after you have completed each part of the application
- Student Section of the application
- Student Section of the application
- Two completed Recommendation Forms (1 Teacher and 1 Counselor)
- Copy of Transcript or most recent Report Card
- Copy of most recent Tax Returns
If you did not file taxes, please attach one of the following documents to verify income
• Copy of W-2 forms from the previous year or income from another governmental source
• A signed statement from the student’s parent/guardian regarding family income
• A signed financial aid application

What Happens Next?
1. After your completed application has been submitted, the team will review your application. (Reminder: You are responsible for ensuring that both reference forms are filled out and returned with your application.)
2. You will receive an email from the Upward Bound team about the status of your application.
3. If you meet the minimum criteria, you will be interviewed by the Upward Bound Team.
ATTENTION:
Your application will not be evaluated until you submit all of the above
information to the Upward Bound Office. New scholars must complete the
Academic Year Component before being enrolled in the Summer Residential
Institute.

I. Student Section
Name*

First NameMiddle NameLast Name
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
(999)999-9999
Cell Phone Number*
(999)999-9999
Work Phone Number
(999)999-9999
Email Address*
example@example.com
Gender

MaleFemale
Date of Birth

MonthDayYear
mm-dd-yyyy
Grade
Social Security Number
999-99-9999
Last four of Social Security Number
9999
Ethnicity

White (Non-Hispanic)Black or African AmericanHispanic or Latino NativeHawaiian or Other pacific IslanderAsianAmerican Indian / Alaskan NativeOther
Are you

U.S. CitizenAn eligible non-citizen (please provide a copy of immigration documentation)OtherNon-U.S. Citizen
Immigration Documentation Upload

Cancelof
Current school attending
What is your cumulative GPA
Do you plan on attending college?

YesNoNot Sure
How did you hear about Upward Bound?

CounselorTeacherPresentationUpward Bound StudentOther
Are you currently enrolled in another college prep program (Upward Bound Math Science, Talent Search or Gear Up)?

YesNo
If an Upward Bound Student referred you, what is their name?

First NameLast Name
Please select the high school courses have taken or are currently taking:
Math

Algebra 1Algebra 2GeometryOther Math (Describe)
Science

Earth ScienceBiologyPhysicsChemistryOther Science
Social Studies

World History IWorld History IIWorld GeographyUS HistoryGovernmentOther History
Language

SpanishFrenchEnglish 9English 10English 11English 12

Please list any other courses you have taken or are currently taking:

	Course Name
1
2
3
4
5
6
7
8

Recommendation

Please include the name and email of a teacher and counselor you would like to have recommend you for our program
Counselor Name

First NameLast Name
Counselor Email
example@example.com
Teacher Name

First NameLast Name
Teacher Email
example@example.com
This is to certify that all information by me is true and correct to the best of my knowledge. Furthermore, I give Virginia Union University's Upward Bound Program permission to receive copies of my educational records and other academic information necessary for participation in the program. This information may be used for any federal reports of the Upward Bound Staff. This release is to be effective throughout my high school and college matriculation.
Student Signature

Clear
Date

MonthDayYear
mm-dd-yyyy

II. Parent/Guardian Section
Parent / Guardian Information

This section must be completed by the student’s parent / guardian. If you have any questions, call the Upward Bound office at (804) 257-5884. Please complete all blanks to avoid processing delays.

Confidentiality of Information

No one is allowed to see the information you provide unless he/she is an employee of the Virginia Union University Upward Bound Program or otherwise authorized to see this information. All information provided in this section is protected by the privacy Act and is not specifically reported to the federal government or U.S. Department of Education. However, the Department of education does have the authority to gather general statistical data about program participants in order to improve and measure the success of the Upward Bound Program.
Parent/Guardian

First NameLast Name
Highest Education Level Completed

Elementary or Junior High SchoolHigh School or GEDVoc./Technical SchoolSome CollegeAssociate’s DegreeCompleted Bachelors Degree
Parent/Guardian Martial Status

MarriedDivorcedSeparatedUnmarriedWidowedOtherOther
Number of adults in household
Number of children in household
Employer's Name
Occupation
Work Number
(999)999-9999
Parent Email
example@example.com
Are you currently receiving public assistance

YesNo
If yes, please select the following

Government assistanceSocial SecurityCompensationUnemploymentRetirementOther
Parent/Guardian

First NameLast Name
Highest Education Level Completed

Elementary or Junior High SchoolHigh School or GEDVoc./Technical SchoolSome CollegeAssociate’s DegreeCompleted Bachelors Degree
Parent/Guardian Martial Status

MarriedDivorcedSeparatedUnmarriedWidowedOther
Number of adults in household
Number of children in household
Employer's Name
Occupation
Work Number
(999)999-9999
Parent Email
example@example.com
Are you currently receiving public assistance

YesNo
If yes, please select the following

Government assistanceSocial SecurityCompensationUnemploymentRetirementOther

List all dependents (including applicant) living in the household.

	Name	Age	Occupation
1
2
3
4
5
6
7
8
9
10

Taxable Income (IRS Form 1040, line 43; IRS Form 1040SR, line 15; IRS Form 1040EZ, line 10.)
I certify by signing below that all of the above information is correct and that any false or misleading information may result in disqualification of the applicant.
Parent/Guardian Signature

Clear
Date

MonthDayYear
mm-dd-yyyy

Student Information Release Form
Permission to release information

For: {main_name}

I authorize The Virginia Union University Upward Bound Program to receive
copies of my Son’s/Daughter’s academic records, including, but not limited to
transcripts, grade reports, test scores, evaluations, attendance, medical records,
disciplinary actions, and other records necessary for participation in the program.
This information may be used for any federal reports of the Upward Bound Staff.
This release is to be effective throughout my high school and college matriculation.
Student's Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Parent/Guardian Signature

Clear
Date

MonthDayYear
mm-dd-yyyy