265287-Tusculum College-UB-2022 Application Form-Ian

Application - Upward Bound 2024-2025
Thank you for your interest in applying to Tusculum University Upward Bound covering Greene, Hamblen, Unicoi and Washington Counties. This is a program dedicated to helping high school students achieve their dreams of attending and graduating from college. Please have both the student and parents/guardians fill out the following application as fully as possible--both a student and parent/guardian will need to sign on this page. You can save your information and come back later to complete it if needed.

Once you submit the application, you will receive an email confirmation of your submission. Our staff will follow up with you after we receive your application to complete the application process. If you have any questions, please call 423-636-7300 ext 5276 or email me, Erin Frizzell, at efrizzell@tusculum.edu.
1. Name*

First NameMiddle NameLast Name
2. School student attends or will attend 2024-2025*
3. Student's Grade Level for school year 2024-2025*

9101112
4. Student's Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
5. Student's Home Phone Number Please include area code. If not applicable, please use 0's Example: (000) 000-0000.*
(999)999-9999
6. Student's Cell Number Please include area code. If not applicable, please use 0's Example: (000) 000-0000.*
(999)999-9999
7. Student's Email Address*
example@example.com
8. Do you have internet access at home?

YesNo
9. Student's Social Security Number*
999-99-9999
10. Student's Date of Birth*

MonthDayYear
MM-DD-YYYY
11. Citizenship Status Students must be U.S. Citizens or Permanent Residents to be eligible for Upward Bound

U.S. CitizenPermanent Resident
12. Student's Gender

MaleFemalePrefer not to answer
13. Preferred pronouns

He/himShe/herThey/them
14. Student's Ethnicity (Select all that apply)

AsianBlack/African AmericanHispanic/LatinoAmerican Indian/Alaskan NativeNative Hawaiian/Pacific IslanderWhite/CaucasianOther - Not Listed Choice
The United States Department of Education requires our program to collect data on participants' race and ethnicity.
15. Please indicate languages, other than English, spoken at home:
16. Please list all co-curricular and other activities in which student is involved, both inside and outside of school. (Examples include: work, athletics, band, student government, clubs, community or church groups, hobbies, or other organizations)
17. Are you currently a participant in any of the following TRIO programs?*

TalentUpward Bound Math & ScienceNone of these apply to me
18. What was your grade point average (GPA) at the end of last semester?*
19. Do you want to go to college after you finish high school?*

YesNo
20. List three careers that interest you. (Things you would like to do after you complete college.)*
21. Please write a brief paragraph about why you want to be an Upward Bound student and how Upward Bound can help you.*
22. Are you willing to attend tutoring sessions weekly, either at your school or online?*

YesNo
23. Are you willing to participate in math and/or science related field trips (during freshmen year only), other college related workshops, college visits, and other cultural events on evenings or weekends regularly?*

YesNo
24. Are you willing to participate in an academic six-week summer residential program at Tusculum University in Greeneville, TN?*

YesNo
25. How did you hear about Upward Bound?
26. I, the student, have read and understand that a failure to follow the Tusculum University Upward Bound Code of Conduct and Honor could result in dismissal from the program at any time.*

Clear
Date*

MonthDayYear
MM-DD-YYYY
A link to the Code of Conduct and Honor can be found here: https://web.tusculum.edu/trio/ub/application-links/code-conduct-honor/
A link to the Code of Conduct and Honor can be found here:

https://web.tusculum.edu/trio/ub/application-links/computer-use-policy/
27. I, the student, have read and understand the UB Computer Use Policy and that if any violations occur, I could be sanctioned by the director or associate director and could result in dismissal from the program.*

Clear
28. Date*

MonthDayYear
MM-DD-YYYY
29. I, the student, give my permission for the Tusculum University Upward Bound Program to use my image/likeness in or on Upward Bound related publications and/or public relations materials. I understand that these items will be used to provide information about UB services and activities. This may include: Newsletters, Videos, Website, Handbook, Brochures, Newspaper and all social media sites. *

Clear
30. Date*

MonthDayYear
MM-DD-YYYY
31. PARENT/GUARDIAN SECTION: With whom does the student live?*

Both ParentsMotherFatherLegal GuardianFoster CareOther
32. Parent Marital Status*

Married - Living TogetherMarried - Not Living TogetherNot Married - Living TogetherSingleDivorcedOther
33. Please list names of all the persons who live in the student’s primary household (including yourself)*
34. Parent/Guardian (1) Full Name:*

First NameLast Name
35. Parent/Guardian (1) Relationship to the Student:*
36. Parent/ Guardian (1) Student resides with me ____ % of the time*
37. Parent/Guardian (1) mailing address (street, city, state, zipcode)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
38. Parent/Guardian (1) home phone number: Please include area code. If not applicable, please use 0's Example: (000) 000-0000.*
(999)999-9999
39. Parent/Guardian (1) mobile phone number: Please include area code. If not applicable, please use 0's Example: (000) 000-0000.*
(999)999-9999
40. Parent/ Guardian (1) Education (check highest level completed):*

ElementaryHigh SchoolSome CollegeAssociate's DegreeBachelor's DegreeGraduate Degree(Master's or Doctorate)
41. Parent/Guardian (1) Occupation*
If this does not apply to you, please indicate N/A
42. Parent/Guardian (1) Employer*
If this does not apply to you, please indicate N/A
43. Parent/Guardian (1) work phone number: Please include area code. If not applicable, please use 0's Example: (000) 000-0000.*
(999)999-9999
44. Parent/Guardian (1) Email*
example@example.com
45. Parent/Guardian (2) Full Name:*

First NameLast Name
46. Parent/Guardian (2) Relationship to the Student:*
47. Parent/ Guardian (2) Student resides with me ____ % of the time*
48. Parent/Guardian (2) mailing address (street, city, state, zipcode)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
49. Parent/Guardian (2) home phone number: Please include area code. If not applicable, please use 0's Example: (000) 000-0000.
(999)999-9999
50. Parent/Guardian (2) mobile phone number: Please include area code. If not applicable, please use 0's Example: (000) 000-0000.
(999)999-9999
51. Parent/ Guardian (2) Education (check highest level completed):*

ElementaryHigh SchoolSome CollegeAssociate's DegreeBachelor's DegreeGraduate Degree(Master's or Doctorate)
52. Parent/Guardian (2) Occupation
If this does not apply to you, please indicate N/A
53. Parent/Guardian (2) Employer
If this does not apply to you, please indicate N/A
54. Parent/Guardian (2) work phone number: Please include area code. If not applicable, please use 0's Example: (000) 000-0000.
(999)999-9999
55. Parent/Guardian (2) Email
example@example.com
56. Household Income: Did the Parent(s)/Guardian(s) of this student file a 2024 federal income tax return?*

YesNo
57. If Yes, please upload a copy of your 2024 federal tax return.

If you cannot upload your tax return, we can accept paper copies or emailed copies as well. efrizzell@tusculum.edu
Cancelof
58. Family Taxable Income:
The information we need is your family's taxable income NOT your total annual income. (Usually line 43 on a 1040.)
59. If you did not file federal tax return, what non-taxable income did you receive? (Check all the apply) If your student is selected and you did not file a tax return you will have to complete an Income Verification Form.

Social SecurityUnemploymentDisabilityAFDCVeterans BenefitsChild Support
60. Are you willing to allow your child to participate in weekly tutoring sessions at your high school or online?*

YesNo
61. Are you willing to allow your child to participate in an academic six-week summer residential program at Tusculum University in Greeneville, TN*

YesNo
62. I, the Parent or Guardian, have read and understand that a failure to follow the Tusculum University Upward Bound Code of Conduct and Honor could result in dismissal from the program at any time.*

Clear
63. Date*

MonthDayYear
MM-DD-YYYY
A link to the Code of Conduct and Honor can be found here: https://web.tusculum.edu/trio/ub-math-science/code-conduct-honor/
A link to the Computer Use Policy can be found here: https://web.tusculum.edu/trio/ub/application-links/computer-use-policy/
64. I, the Parent or Guardian, have read and understand the UB Computer Use Policy and that if any violations occur, my child could be sanctioned by the director or associate director and could result in dismissal from the program.*

Clear
65. Date*

MonthDayYear
MM-DD-YYYY
66. I, the Parent or Guardian, give my permission for the Tusculum University Upward Bound and to use my child's image/likeness in or on Upward Bound related publications and/or public relations materials. I understand that these items will be used to provide information about UB services and activities. This may include: Newsletters, Videos, Website, Handbook, Brochures, Newspaper and all social media sites. *

Clear
67. Date*

MonthDayYear
MM-DD-YYYY
68. I certify that the above information and income data is correct to the best of my knowledge; further, I understand that all information provided will be held in strictest confidence. *

Clear
69. Date*

MonthDayYear
MM-DD-YYYY
70. SCHOOL RECORD RELEASE: I, the parent or guardian, hereby grant permission to the appropriate office of the high school and/or postsecondary institution attended by the student to issue a transcript/financial aid, and enrollment information for this student to the Upward Bound Program, Box 5053, Tusculum University, Greeneville, TN 37743. *

Clear
71. Date*

MonthDayYear
MM-DD-YYYY
72. I, the student, hereby grant permission to the appropriate office of the high school and/or postsecondary institution attended by the student to issue a transcript/financial aid, and enrollment information for this student to the Upward Bound Program, Box 5053, Tusculum University, Greeneville, TN 37743.I, the student, hereby grant permission to the appropriate office of the high school and/or postsecondary institution attended by the student to issue a transcript/financial aid, and enrollment information for this student to the Upward Bound Program, Box 5053, Tusculum University, Greeneville, TN 37745. *

Clear
73. Date*

MonthDayYear
MM-DD-YYYY

Application - Upward Bound 2024-2025