Savannah State University-UB-Application Form

*Please submit your most recent report card/transcript to upwardbound@savannahstate.edu

SAVANNAH STATE UNIVERSITY

UPWARD BOUND PROGRAM

BOX 20488 * 3219 COLLEGE STREET * SAVANNAH, GEORGIA 31404

(912) - 358-3477 * FAX (912) - 358 -3687

Email: upwardbound@savannahstate.edu

APPLICATION FOR ADMISSION

(Please Complete All Sections of Application)
Upload current report card*

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Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone 1
(999)999-9999
Telephone 2
(999)999-9999
E-mail Address*
example@example.com
Gender

MaleFemale
Date of Birth

MonthDayYear
mm-dd-yyyy
Age
I am a United Stated citizen.

YesNo
Ethnic Origin (REQUIRED FOR STATISTICAL PURPOSES):

African AmericanAmerican Indian/Alaska NativeAsian/Pacific IslanderEuropean American (Caucasian)HispanicMore than one ethnic origin (Specify)
Health:

ExcellentGoodFairPoorList any physical disabilities/serious health conditions
Select School:
Please select

Free lunchReduced lunchNeither
Please select

9th grade10th grade11th grade
Counselor's Name

First NameLast Name
Emergency Contact Person

First NameLast Name
Relationship to you
Telephone
(999)999-9999
TO BE COMPLETED BY PARENT/GUARDIAN
Parent's/Guardian's Marital Status:

MarriedDivorcedSeparatedWidowedSingle
Father's/Guardian's Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parental Email:
example@example.com
Employer
Occupation
Phone
(999)999-9999
Did you graduate from high school?

yesno
Did you graduate from college?

yesno
Name of College?
College was:

4 year2 yearOtherNeither
Annual Gross Income
$
Mother's/Guardian's Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer
Occupation
Phone
(999)999-9999
Did you graduate from high school?

yesno
Did you graduate from college?

yesno
Name of College?
College was:

4 year2 yearother
Annual Gross Income
$

List each child living in the household (excluding applicant) below

	NAME	AGE	CHECK IF SUPPORTED BY PARENT/GUARDIAN	SCHOOL ATTENDING
1
2
3

Other Income (Please attach official documentation):

Social SecurityVeterans BenefitsTANF/WelfareRetirementUnemploymentMedicaid Number
Please attach necessary documentation

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Most recent IRS1040 document

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I affirm that the information provided is complete and correct. Any deliberate or omission of date supplied may result in denial of placement or dismissal from the Upward Bound Program
Student's Signature

Clear
Parent's/Guardian's Signature

Clear
Parent/Legal Guardian

First NameLast Name
Parental Authorization for Release of Student's Records

Privacy Act

In accordance with the Family Educational Rights and Privacy Act. I understand that all information concerning my child and me is confidential and will not be revealed to anyone except Upward Bound Personnel.

I, {name68}, Parent/Legal Guardian of {main_name}, authorize the Superintendent of Schools or his/her Designee(s) to release all records listed below to the following Agency and its Designee(s):

Savannah State University

Upward Bound Program

Box 20488

3219 College Street

Savannah, Georgia 31404

Telephone: (912) 358-3477 Fax: (912) 358-3687

Email: upwardbound@savannahstate.edu

Records:
- Grade Transcript/Progress Reports
- Psychological Educational Reports
- Special Education Placement Data
- Attendance Data
- Testing Data
- Immunization Data
Student Social Security Number
999-99-9999
I further authorize the release of all information regarding my child's educational, physical and social adjustments in school, as long as he/she participates in the Upward Bound Porgram.

I also understand that the prior to transfer, I may review and have all/any part of these records properly interpreted by making such request of the Principal or appropriate Board of Education Personnel.

Additional permission Authorization Waiver

I agree to allow all Upward Bound and its constituents to photograph or digitally record my child for use in publications (Newsletters/Articles) and Social Media platforms (Twitter, Facebook, Linkedin, Youtube, and Instagram).

I further grant authorization to allow my child to participate in all workshops, seminars, classes, surveys, and field trips throughout their participation with the Upward Bound Program at Savannah State University.
Parent(S)/Guardian(s) Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Student's Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Please write a brief autobiographical sketch. Include experiences, interest, activities, and future plans and reasons for desiring to participate in the Upward Bound Program.
File Upload

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Upward Bound Program

NEEDS ASSESSMENT
Name

First NameLast Name
1. Are you currently participating in any of the following?

Educational Talent SearchGEAR UP GeorgiaOther
2. How many years of college do you plan to complete after high school graduation?

1-6 months (Certificate Program)1-2 years (Community Technical College)3-5 years (Bachelors Degree)6 or more (Masters/Doctorate Degree)Not Sure
3. Currently, what career do you wish to pursue?
4. Do you know facts about this career (what to study in college, schools that offer the major, classes needed to take, etc.)?

YesNo
5. To prepare for college, are you knowledgeable of the academic classes that should be studied (college prep curriculum)?

YesNo
6. Do you need assistance applying for college, financial aid, and scholarships?

YesNo
7. Do you need assistance in preparing for ACT, SAT, or PSAT Tests?

YesNo
8. Do you need to develop/improve your study skills?

YesNo
9. Do you need enrichment/tutoring in any subject?

YesNo
List:
Goal(s) you have set for yourself:
Academic:*
Program:*
Overall:*