Appalachian State University-UBMS-2022 Application Form

Appalachian State University-UBMS-2023-2024 Application Form
ATTENTION APPLICANT
- Please review your materials and answers carefully. Direct questions to: upwardbound@appstate.edu
- We will call you and your parents to confirm receipt of your application. Interviews will be held at your school after we receive your application.
- Please submit this application online
Questions? Call your school’s coordinator:
Aaron (828) 773-4951 (Watauga)
Kim (859) 327-8726 (Ashe, Freedom)
Matthew (919) 426-0174 (Alleghany, Ashe)
Jessica (828) 263-7616 (Avery, West Wilkes, McDowell )

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 US 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 program. The principle purpose for collecting this information is to administer the program, including tracking and evaluating participants’ academic progress. The information that is collected on this application will be retained in the program files and may be released to other Department officials in the performance of official duties

PART 1: STUDENT AND ELIGIBILITY INFORMATION
Student's Full Name:*

First NameMiddle NameLast Name
High School you attend:
Power School ID:
Grade:
Current Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different from home):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Telephone Number:
(999)999-9999
Student's Cell Number:
(999)999-9999
Student's School E-mail:
example@example.com
Student's Personal E-mail:*
example@example.com

Please respond these questions (check one box per questions). To be eligible for Upward Bound, you must answer "yes" to one of these questions.

	Yes	No
1. Are you a citizen or national of the United States?
2. Are you a permanent resident of the United States?
3. Do you plan to live permanently in the United States? Please provide evidence from the Immigration and Naturalization Service of your pending application to become a permanent resident.
4. Are you a permanent resident of Guam, the Northern Mariana Islands, or the Trust Territory of the Pacific Islands?
5. Are you a resident of the Freely Associated States - Federated States of Micronesia, the Republic of the Marshall Islands, or the Republic of Palau?

Birthplace:
(city, state, country)
Birth Date:

MonthDayYear
mm-dd-yyyy
If applicable, Permanent Resident #:
Date Issued:

MonthDayYear
mm-dd-yyyy
If applicable, Immigrant Visa #:
Date Issued:

MonthDayYear
mm-dd-yyyy
Are you aware of any disabilities (learning, physical, emotional, etc.) for which you would need additional assistance?

YesNo
If so, please attach a statement detailing the disability as well as any supporting documents that you believe will assist the program to understand the disability.

Cancelof
How did you first hear about Upward Bound?
Upward Bound is a federal TRIO program for students from low-income families AND/OR who will be in the first generation in their family to graduate from a 4-year college. To be eligible for admission to Upward Bound, students must meet one of these criteria and have the potential and desire to go to college. Please answer the following questions about these topics.
Parental Educational Background Information:
Highest grade mother completed:

9th10th11th12thOther
Graduated from a 4-year college?

YesNo
Highest grade father completed:

9th10th11th12thOther
Graduated from a 4-year college?

YesNo
Household Income Information:
**This information is kept confidential and is required in order to evaluate your child’s eligibility for admission to the Upward Bound Program.**
How many people, including the applicant, are currently living in your household?
Parent/Guardian taxable income for last year was:
This is found on Line 43-form 1040 or Line 27-1040A or Line 6-form 1040EZ

The Upward Bound program is supported by a federal TRIO grant. Therefore, it is necessary to verify the income eligibility of the applicant’s family. Parents may provide a recent copy of their federal income tax return (1040, 1040A or 1040EZ) if possible.

If you have questions about this requirement, please call the office 828-262-8016 or talk with your school’s Upward Bound coordinator.

Federal TRIO Programs - Current-Year Low-Income Levels (Effective January 15, 2020 until further notice)

Size of Family Unit:	Income at or below:
1	$21,870
2	$29,580
3	$37,290
4	$45,000
5	$52,710
6	$60,420
7	$68,130
8	$75,840

For family units with more than eight members, add $6,720 for each additional family member

Please list your current classes and teachers:

	Class/Period	Teacher
1
2
3
4
5

PART 2: LANGUAGE INFORMATION
Are you enrolled in an English as a Second Language class?

YesNo
What is your primary language?
Other than English, what other languages do you speak?

PART 5: STUDENT STATEMENT
Please respond to the following question. Your response should be at least two (2) paragraphs in length.
Tell us about yourself and about why Upward Bound should select you as a participant. What do you hope to gain from this experience?

PART 6: PARENT / GUARDIAN COMMITMENT
STATEMENT OF COMMITMENT

As the parent/guardian of {main_name} I understand the Appalachian State University Upward Bound Program is committed to helping students grow personally, culturally, and academically. Acting as the applicant’s parent and/or legal guardian we all agree and understand that the applicant will participate in the following ways if he/she is admitted into the program:
- Attend weekly advising sessions at their high school with their academic coordinator
- Attend all weekend academies held on the Appalachian State University campus
- Attend residential summer academies at Appalachian State University each summer of high school (students will return home on the weekends)
- Participate in campus tours, cultural and recreational activities as offered through the program
- Participate in the Upward Bound Program through high school graduation
- Enroll in university or community college in the semester following high school graduation.
Student Signature:

Clear
Date:

MonthDayYear
mm-dd-yyyy
Mother Signature:

Clear
Date:

MonthDayYear
mm-dd-yyyy
Father Signature:

Clear
Date:

MonthDayYear
mm-dd-yyyy
Legal Guardian Signature:

Clear
Date:

MonthDayYear
mm-dd-yyyy

PART 7: RELEASE OF INFORMATION CONSENT
PERMISSION TO RELEASE INFORMATION TO UPWARD BOUND
Applicant's name:

First NameLast Name
Date:

MonthDayYear
mm-dd-yyyy
- I authorize my child’s high school to release to the Appalachian State University Upward Bound staff my child’s school records as needed. These records include current grades, class rank, and test scores, as well as past school records.I permit the Upward Bound staff to discuss my child's academic and/or personal concerns with my child via in-person and online meetings which can include phone calls, text, social media, questionnaires, surveys, and forms. I also permit the Upward Bound staff to discuss my child’s academic and/or personal concerns with high school personnel (teachers, guidance staff, and administrators), to monitor academic progress and assess academic and personal needs. This release also gives permission for high school personnel to contact Upward Bound staff and convey information relevant to the academic and personal progress of my child. I understand that this information is protected by the Privacy Act. I understand that Upward Bound will access the National Student Clearinghouse database for information about my student’s enrollment in post-secondary education. My authorization will continue in effect unless a written withdrawal of permission is submitted to my child’s high school and the Upward Bound staff. application is accurate to the best of my knowledge.
Signature of Parent or Legal Guardian:

Clear
Date:

MonthDayYear
mm-dd-yyyy
Signature of Student:

Clear
Date:

MonthDayYear
mm-dd-yyyy

Appalachian State University-UBMS-2023-2024 Application Form

Parental Educational Background Information:

Household Income Information:

Parent or Legal Guardian #1 - REQUIRED

Parent or Legal Guardian #2 - IF APPLICABLE

PERMISSION TO RELEASE INFORMATION TO UPWARD BOUND