Kent State University-PHUB-UB-Application Form

Upward Bound Programs
Student Application
Phone: 330-672-2920 Fax: 330-672-5339
Email: ubhealthprofessions@kent.edu
Website: http://www.kent.edu/upwardboundprogram

Today's Date*

MonthDayYear
mm-dd-yyyy
Student Name*

First NameLast Name
Gender

MaleFemale
Grade*

89101112
Preferred T-Shirt Size*

XSSMLXL2XL3XL
Dietary Needs
Current Age*
Indicate the Parent with whom the student resides during the academic year*

MotherFatherBothGuardian
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number*
(999)999-9999
Parent Name*

First Namejudg
Parent Email Address
example@example.com
Parent Cell Phone Number
(999)999-9999
Student Cell Phone Number
(999)999-9999
Student Email Address*
example@example.com
Ethnicity*

HispanicNon-Hispanic
Race (mark all that apply)*

Black or African-AmericanWhiteNative Hawaiian or Other Pacific IslanderAmerican Indian or Alaskan NativeAsian
Student Social Security Number
999-99-9999
Language Spoken at Home*
Date of Birth*

MonthDayYear
mm-dd-yyyy
Name of Current School*
Guidance Counselor

First NameLast Name
IEP on File

YesNo
If yes, please attach

Cancelof

List all persons living in your home, including yourself. (USE ADDITIONAL SHEET IF NECESSARY)

Rows	Name	Age	Relationship	Occupation or Name of School
1
2
3
4
5
6
7

Additional Sheet

Cancelof
I certify that all of the above information is true and correct. I understand that this information is being provided for the receipt of federal funds.
Parent/Guardian's Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy

Father/Male Guardian Name

First NameMILast Name
Highest educational level completed

High School (9-12 grade)Associates Degree (2 years)Bachelor’s Degree or beyond (4+ years)Other
Mother/Female Guardian Name

First NameMILast Name
Highest educational level completed

High School (9-12 grade)Associates Degree (2 years)Bachelor’s Degree or beyond (4+ years)Other
Student Residency Status*

A U.S. CitizenAn eligible non-citizen (provide documentation)Other
Residency Documentation (Complete only if applicant is an eligible non-citizen)

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**FOR PARENTS OR LEGAL GUARDIANS ONLY**
INCOME INFORMATION
(THIS INFORMATION WILL BE KEPT STRICTLY CONFIDENTIAL AS REQUESTED PER FEDERAL GUIDELINES)
PLEASE CALL IF YOU HAVE ANY QUESTIONS REGARDING THIS SECTION
330-672-2920 OR 1-888-215-9637
Line 15 of the 1040 form (Taxable Income):
Total number in Household
OR
Families receiving Aid to Dependent Children or other public benefits: ADC Case Number

Families receiving public benefits please enter the case number where applicable;

Rows	Case Number
Temporary Assistance for Needy Families (TANF)
Supplemental Nutrition Assistance Program (SNAP)
Medicaid and Children’s Health Insurance (CHIP)
Other Public Benefits (Enter Name and Case #)

Other (e.g., SNAP benefits, Medicaid)
Foster Child: Is the student a foster child?

YesNo
SIGNATURE: An adult household member must sign this statement and complete the requested information BEFORE the application can be approved.

I certify that all of the above information is true and correct. I understand that this information is being provided for the
receipt of federal funds.
Parent/Guardian's Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy

Parent/Guardian Name 1

First NameLast Name
Parent/Guardian Name 2

First NameLast Name
Student Name

First NameLast Name
SS#
999-99-9999
Date

MonthDayYear
Date
In each case, Parent(s) /Guardian(s) is a reference to the person(s) with whom the applicant lives. If there are co-heads of household, both must sign.

To KENT STATE UNIVERSITY UPWARD BOUND AND THE APPROPRIATE SCHOOLS:

I/We (Parent/Guardian Name 1) and (Parent/Guardian Name 2) do hereby authorize you to release information from the comprehensive and cumulative school records of my/our child, (Student’s name listed above) (SS # listed above), such as grades, class rank, school attendance, discipline issues, school activities, teacher evaluations, standardized test scores, academic performance, individualized education plan and forwarding of official transcripts, to bona fide representatives of the secondary schools, accredited colleges, Kent State University Upward Bound Programs, and other educational institutions, who are seeking information concerning __ (student’s name) as a participant of the Kent State University Upward Bound Programs for data collection/follow-up and general informational purposes. This information can be released when the student mentioned above is in regular enrollment or when the student has transferred to a new location.

I/We, certify that I/We am/are the Parent(s), Custody Parent(s), or Guardian(s) of(student’s name listed above) and that I/We signed this release form of the Kent State University Upward Bound Programs.
Should you desire that any information listed above not be released, please list that information here:
Ohio and Federal laws require authorization for release of personal data from school records.
Applicant's (student's) signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Parent/Guardian signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Parent/Guardian signature (optional)

Clear
Date

MonthDayYear
mm-dd-yyyy
Student Needs Assessment
My parents/guardians want me to go to college

YesNo