Western Kentucky University-Bowling Green-VUB-Application Form

PARTICIPANT APPLICATION
- Name:*
  
  First NameMILast Name
- SSN:
  999-99-9999
- Date of Birth:
  
  MonthDayYear
  mm-dd-yyyy
- Sex:
  
  MaleFemale
- Address:
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- County:
- Email:*
  example@example.com
- Cell Phone:
  (999)999-9999
- Home Phone:
  (999)999-9999
- Emergency Contact:
  
  First NameLast Name
- Emergency Phone:
  (999)999-9999
- May we text you?
  
  YesNo
- U.S. Citizen or Permanent U.S. Resident:
  
  YesNo
- Ethnic/Racial Origin: Hispanic/Latino:
  
  YesNo
- Please select one of these five choices:
  
  American Indian/Alaskan NativeAsianBlack or African AmericanWhiteNative Hawaiian/Other Pacific Islander
- Employment Status:
  
  Employed F/TEmployed P/TUnemployedRetired
- INSTRUCTIONS
  
  Make sure you only use your taxable income.
  
  To determine your taxable income, refer to your last federal tax return. It is your income after all of your deductions.
- Taxable Income:
  
  No taxable income$1-$23,940$23,941-$32,460$32,461-$40,980$40,981-$49,500$49,501-$58,020$58,021-$66,540$66,541-$75,060$75,061-$83,580$83,581 or above
- Total number of dependents (including yourself):
- Certified Disability:
  
  YesNoPending
- Active duty for more than 180 days: (30 days active duty required for reserve/national guard)
  
  YesNo
- Service-connected disability:
  
  YesNo
- Date Entered Service:
  
  MonthDayYear
  mm-dd-yyyy
- Date Separated:
  
  MonthDayYear
  mm-dd-yyyy
- Branch of Service:
  
  Air ForceNavyCoast GuardArmyNational GuardMarinesReserves (all branches of service)Space Force
- Discharge:
  
  HonorableMedicalBad ConductDishonorableGeneralUndesignatedOther than HonorableOther
- How much school have you completed?
  
  High School DropoutHigh School GraduateGED/HS EquivalencyHigh School w/ Some CollegeGED or Equivalent w/ Some College
- Last School Attended Name:
- Last School Attended Location:
- Date Last Attended:
  
  MonthDayYear
  mm-dd-yyyy
- What are your educational goals?
  
  GED CompletionCollege/UniversityCommunity CollegeVocational/Technical School
- How can VUB help you attain your educational goals?
  
  School Admissions CounselingFinancial Aid CounselingCareer CounselingAcademic Refresher SkillsOther
- Did either of your parents/guardians who raised you graduate from a 4-year college before you turned 18?
- Father
  
  YesNo
- Name while in school:
  
  First NameLast Name
- Mother
  
  YesNo
- Name while in school:
  
  First NameLast Name
- How did you hear about Veterans Upward Bound?
  
  Community Agency (i.e. Employment Services)Veterans AgencyAdvertisement/Media (including mailings)Website/FacebookReferral (Educational Institution)Word of Mouth/Walk-inReferral (another TRIO program)Referral (non-TRIO program)Other
- This certification is required for participation in the VUB program.
  
  VUB will not release any confidential information without your written consent.
  
  • I authorize the release of my school and military records (including, but not limited to, transcripts, standardized test scores, financial aid information, and an unredacted copy of DD Form 214) to the VUB program.
  • I authorize the exchange of information between the VUB program and other agencies, as necessary, to assist me in achieving my educational goals.
  • I authorize the exchange of information between the VUB program and the Department of Education to evaluate the VUB program’s progress.
  • I authorize the use of my name, image, intended school and major, and/or testimonial statements for use on the VUB website, Facebook page, or any other marketing efforts.
  • I understand that there is a zero tolerance policy for alcohol, illegal drugs, weapons, or harassing, disrespectful, or threathening behavior. I am aware that failure to comply could result in dismissal from the
  program.
  • I understand that the information provided on this application is true and correct to the best of my knowledge.
- Signature
  
  Clear
- Date
  
  MonthDayYear
  mm-dd-yyyy

PARTICIPANT APPLICATION