Gloria J. Taylor Foundation-TFD 215-UB-Application Form

The Gloria J. Taylor Foundation
Upward Bound Program

"Preparing Our Future For The Future"
Application
WWW.GJTF.ORG

Please note that all applications are accepted for review regardless of race, color, national origin, religion, gender or disability (U.S. Dept. of Education -GEPA Section 427).

GJTF UPWARD BOUND - APPLICATION CHECKLIST

PLEASE MAKE SURE YOU COMPLETE ALL ITEMS LISTED ON THIS CHECKLIST. YOUR
APPLICATION WILL NOT BE CONSIDERED UNTIL IT IS COMPLETE.
Name of Applicant*

First NameLast Name
High School

TF NorthTF SouthRich NorthRich South
Current Grade Level

9th10th11th
- Part I Student Information with applicant signature
- Part II Family Information, Education
  - Part II Family Information, Financial
  - Prior year federal tax return (Dependent must be listed on return.)
- Part III Letter of Recommendation forms (MUST RETURN 2 OF THE 3 RECOMMENDATION SHEETS)
  - Math or Science
  - English
  - Counselor or Principal
- Part IV Academic Records Release Statement
  - Copy of 8th grade transcript (applies to 9th Grade Only)
  - Most recent high school transcript
  - State Standardized test scores if not on transcript
- Part V Student Essay:
- Part VI Photo Release form
  - Parental Release for Student Travel
  - Emergency Medical Authorization/History Form
Please make sure all required forms have all the necessary signatures, including your signature as well as parent/guardian signature.

Mail COMPLETED APPLICATIONS to:
The Gloria J. Taylor Foundation
Upward Bound Program
20080 Governors Drive
Olympia Fields, Illinois 60461
Scanned applications can be sent to info@gjtf.org

Part 2 - Family Information, Education
Federal eligibility requirements for the GJTF Upward Bound Program require each applicant be a first-generation college student and/or low income. A first-generation college student is defined as a student where neither parent has earned/received a bachelor's degree from a college or university.

Please list below only those who are currently living with the applicant and providing financial assistance.
Father's (Guardian's) Name

First NameLast Name
Phone
(999)999-9999
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number
XXX-XX-9999
Educational Level (check highest level completed)

High SchoolBA/BS
If high school, specify grade
Major?
Occupation
Place of Employment
Phone
(999)999-9999
Mother's (Guardian's) Name

First NameLast Name
Phone
(999)999-9999
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number
XXX-XX-9999
Educational Level (check highest level completed)

High SchoolBA/BS
If high school, specify grade
Major?
Occupation
Place of Employment
Phone
(999)999-9999
Is a language other than English spoken in the home? If yes, please specify
CONFIDENTIALITY OF INFORMATION

The financial and educational information you provide to the Upward Bound director is reported to the Department of Education and is protected by the Privacy Act. No one may see the information unless they work with or for the Upward Bound project or are specifically authorized by the Department of Education to evaluate the project. The Department of Education has authority to gather information to help make Upward Bound a better project (20 USC 1231a). Great care is taken to make sure that the personal information collected on Upward Bound students is kept confidential. Information or records relating to individual Upward Bound students or group(s) of students who are participating or have participated in Upward Bound projects shall not be disclosed to any person, group, agency, or organization without the express consent of the Director, and U.S. Department of Education.

Part 4 - Release of Academic School Records
I authorize the Upward Bound Program of the Gloria J. Taylor Foundation to access and/or receive copies of my academic transcripts, attendance records, student schedules, grade reports, report cards, and any other academic information and test results necessary to complete the program's application process. I authorize my high school counselor and or other administration to release these records to the Gloria J. Taylor Foundation (GJTF) Upward Bound Program from the present through my child's post-secondary graduation.
Records to be released

TranscriptsState Standardized Test ScoresFinancial Aid InformationACT/SAT ScoresPost-secondary Enrollment Status
I certify that this authorization has been made voluntarily.
Student's Name

First NameLast Name
School
Student Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Parent/Guardian Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
This consent is effective for the entire duration my child is in this program or until he/she is turns 18 years of age, whichever comes first.

Privacy Act

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 Upward Bound 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 Upward Bound programs. The principle purpose for collecting this information is to administer the program, including tracking and evaluating participant's academic progress. The information that is collected on this form will be retained in the program files and may be released to Department of Education officials in the performance of official duties.
Will you be able to attend weekly and mandatory after school tutoring sessions?

YesNo
Will you be able to attend the Six-Week Summer Enrichment Institute with GJTF each summer?

YesNo

Part 5 - Student Essay
Please write a personal essay telling us more about you. The essay is a critical part of your application. If you need extra space, please attach another piece of paper to this form. Your essay should be neatly typed or printed in black ink. (Attach extra paper if you need more space for your essay)
Write an essay describing yourself (500 words). Include activities you are involved in outside of school (work, church, community, hobbies, and responsibilities at home)
Upload for additional space

Cancelof

Photo Release Form
If admitted into the Gloria J. Taylor Foundation (GJTF) Upward Bound Program, I hereby grant GJTF permission to use my son/daughter's photograph. I understand that my image may be used in a wide variety of promotional materials including, newsletters, flyers, posters, brochures, advertisements, fundraising letters, annual reports, press kits, websites, social media networking sites and other print and digital communication.

I understand and agree that these materials will become the property of the Gloria J. Taylor Foundation and will not be returned.

I have read this release before signing below and I fully understand the contents, meaning, and impact of this release.
Student Name

First NameLast Name
Date

MonthDayYear
mm-dd-yyyy
Student Signature

Clear
Parent's Name

First NameLast Name
Date

MonthDayYear
mm-dd-yyyy
Parent Signature

Clear

Parent Release for Student Travel
The Gloria J. Taylor Foundation (GJTF) to provide transportation for my child to program activities. I hereby release the GJTF- Upward Bound Program from any responsibility for any criminal act of malice, vandalism, theft and any other unlawful behavior during his/her trips sponsored by The Gloria J. Taylor Foundation.

In return for my son/daughter's attendance to program activities, I fully and forever RELEASE, WAIVE AND DISCHARGE, AND COVENANT NOT TO SUE, The Gloria J. Taylor Foundation (including, but not limited to, its board of directors, employees, students acting as employee and representatives), from and for any and all demands, claims, actions, suits, damages, losses, liabilities, costs and expenses (including, but not limited to, court costs and attorney's fees), from any causes whatsoever (including, but not limited to, travel delays, property damage and loss, bodily injuries, sickness, disease and death), directly or indirectly arising in connection with my son/daughter's participation in the GJTF UB Program.

If for any reason my son/daughter engages in an unlawful act and is detained by the local police while traveling with the GJTF UB program, an attempt will be made to notify me. In the event that I can or cannot be reached, I understand that the program staff will leave my son/daughter in the custody of the local police and I assume full responsibility to make arrangements on his/her behalf.
Student's Name

First NameLast Name
Date

MonthDayYear
mm-dd-yyyy
Parent/Guardian Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
This consent is effective for the entire duration my child is in this program or until he/she is turns 18 years of age, whichever conies first.

Part 6 - Emergency Medical Authorization/History Form
Through the year, we take our students on a variety of field trips. Therefore, it is necessary that we have an accurate medical history in the event that emergency treatment is required. All information is confidential. Any student without a completed and signed Medical Information Form will not be allowed to participate in field trips
Student Name

First NameMILast Name
Birth Date

MonthDayYear
mm-dd-yyyy
Gender

MaleFemale
Student ID#
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Name

First NameLast Name
Parent/Guardian Email
example@example.com
Cell Phone Number
(999)999-9999
Work Phone Number
(999)999-9999
Emergency Contact's Name

First NameLast Name
Emergency Contact's Number
(999)999-9999

MARK ALL ITEMS "YES" OR "NO". PLEASE PROVIDE DETAILS WHEN ANSWER IS" YES"!

	Yes or No	More Detail
Diabetes
Heart Defects
Asthma
Convulsions/Epilepsy
Allergies (include medications, foods, insect bites, etc.)
Currently taking medication (specify)
Physical Restrictions (specify)
Currently under doctor's care (detail)
Any Hearing Deficiencies
Any Mental Disorders

FAMILY HEALTH INSURANCE INFORMTION

(Please be aware that few doctors will directly bill out of state patients.)
Carrier
Group#
Policy#
Carrier Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insured
Relationship to Insured
ID#
Please list any details to items marked "yes" that have not been explained above. List any current or past medical conditions that may require treatment.
My signature, affixed to this document, authorizes the Gloria J. Taylor Foundation Staff to provide medical services to my child, {main_name}, if necessary. Follow up medical care is also authorized. (1) The administration of any treatment deemed necessary by a doctor, or, in the event the designated preferred practitioner is not available, by another licensed physician or dentist, and (2) The transfer of the child to any hospital reasonably accessible. I will not in any way hold The Gloria J. Taylor Foundation responsible for any treatment deemed necessary for medical services.

TO BE SIGNED BY PARENT/GUARDIAN
(Must be signed for your child to participate on the field trips)
Parent/Guardian Signature

Clear
Date

MonthDayYear
mm-dd-yyyy

Federal TRIO Programs Prior-Year Low-Income Levels

(Effective January 15, 2020)

Size of Family Unit	48 Contiguous States, D.C., and Outlying Jurisdictions	Alaska	Hawaii
1	$18,735	$23,400	$21,570
2	$25,365	$31,695	$29,190
3	$31,995	$39,990	$36,810
4	$38,625	$48,285	$44,430
5	$45,255	$56,580	$52,050
6	$51,885	$64,875	$59,670
7	$58,515	$73,170	$67,290
8	$65,145	$81,465	$74,910

For family units with more than eight members, add the following amount for each additional family member; $6,630 for the 48 contiguous states, the District of Columbia and outlying jurisdictions; $8,295 for Alaska; and $7,620 for Hawaii.

The term "low-income individual" means an individual whose family's taxable income for the preceding year did not exceed 150 percent of the poverty level amount.

The figures shown under family income represent amounts equal to 150 percent of the family income levels established by the Census Bureau for determining poverty status. The 2019 poverty guidelines went into effect as of January 11, 2019. Federal Register notice was published February 1, 2019