Avila University-UB-Application Form

Upward Bound Application Form
Upward Bound Program

Avila University

11901 Wornall Rd., Kansas City, MO 64145

Office: (816) 501-0441 - Fax: (816) 501-2462

Email: jaylan.waxter@avila.edu - Website: www.avila.edu
What is TRIO Upward Bound?

The Federal TRiO Programs (TRiO) are federal outreach and student services programs in the United States designed to identify and provide services for individuals from disadvantaged backgrounds. They are administered, funded, and implemented by the United States Department of Education.

Upward Bound, in particular, provides fundamental support to high school participants in their preparation for college entrance. The program provides opportunities for participants to succeed in their precollege performance and ultimately in their higher education pursuits. Upward Bound serves high school students from low-income families and high school students from families in which neither parent holds a bachelor's degree. The goal of Upward Bound is to increase the rate at which participants complete secondary education and enroll in and graduate from institutions of postsecondary education.

FREE services offered by Upward Bound
- Tutoring
- Extra Academic Enrichment
- ACT Prep
- Advising
- College Readiness Advising
- College Visits
- Career Exploration
- Cultural/Social Exposure
- Summer Programming
Application Process
1. Fill out the attached application in its entirety (an incomplete application will not be accepted) and submit.
2. After your application is reviewed, you will be contacted by email or phone about your eligibility status and to possibly set up an interview.
3. Both student and parent/guardian(s) participate in an interview process.
4. Notification of acceptance
- To be completed by the Student.
- Today's Date
  
  MonthDayYear
  mm-dd-yyyy
- Name
  
  First NameMiddle NameLast Name
- Social Security Number
  999-99-9999
- Date of Birth
  
  MonthDayYear
  mm-dd-yyyy
- Gender
- Home Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Student Cell Phone
  (999)999-9999
- Home Phone
  (999)999-9999
- Student Email Address
  example@example.com
- Please indicate your preferred method of contact
- Current Grade Level (8th-12th)
- High School (if you are a junior high/middle school, which high school will you attend next year?)
- Anticipated high school graduation year
- Please check if you have any of the following (optional)
  
  Other
- Are you a U.S. citizen?
- If not, are you a permanent resident?
- If not, are you a resident alien?
- Please provide your resident alien number
- Please attach a copy of your INS card.
  
  Cancelof
- What is your ethnic background?
- What is your racial background?
- Do you participate in any other college access programs (i.e. Upward Bound, Talent Search, GEAR UP, etc.)?
- If yes, please indicate which program
- How did you hear about us?
  
  Other
- If a student, counselor, teacher, or administrator referred you, please write their name in the space below.
  
  First NameLast Name
- Student T-Shirt Size
- To be completed by the Parent/Guardian.
- Parent/Guardian 1's Information
- Relation to Student
  
  Other
- Full Name
  
  First NameLast Name
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Cell Number
  (999)999-9999
- Would you like to receive text messages?
- Home Number
  (999)999-9999
- Email
  example@example.com
- Employer
- Job Title
- Work Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Work Number
  (999)999-9999
- Can we contact you at work?
- Do you reside with the student?
- Marital Status
- What is your highest grade level/degree earned?
- Parent/Guardian 2's Information
- Relation to Student
  
  Other
- Full Name
  
  First NameLast Name
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Cell Number
  (999)999-9999
- Would you like to receive text messages?
- Home Number
  (999)999-9999
- Email
  example@example.com
- Employer
- Job Title
- Work Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Work Number
  (999)999-9999
- Can we contact you at work?
- Do you reside with the student?
- Marital Status
- What is your highest grade level/degree earned?
- To be completed by the Parent/Guardian.
- The Upward Bound Program at Avila University and the United States Department of Education require all applicants to submit a signed statement of tax information from their parent/guardian’s most recent filed tax returns. Please, fill out the following information as it relates to your particular situation.
- Tax Year
- Please choose one of the following prompts that fit your situation
- I did not file taxes for this tax year because:
- My family's taxable (not gross) income was:
  Your taxable income can typically be found at the end of the first page of your 1040 tax form on line 15.
- My family size was:
- I,
  
  First NameLast Name
- certify, under penalty of perjury, that the financial information provided above in this application is accurate and true.
- Parent/Guardian's Printed Full Name
  
  First NameLast Name
- Parent/Guardian's Signature
  
  Clear
- Date
  
  MonthDayYear
  mm-dd-yyyy
- The Upward Bound Program at Avila University will secure and maintain your information in strictest confidence. Please contact Upward Bound if you have any questions or concerns regarding your personal financial information.
- To be completed by the Student & Parent/Guardian.
  
  I hereby authorize the of release transcripts, grades, progress reports, standardized test scores (included but not limited to EOC, MAP, ACT, SAT, PLAN, PSAT scores, & National Student Clearinghouse), attendance records, conduct and behavior reports, and other educational information to the Upward Bound Program at Avila University. In addition, the Upward Bound staff may meet with my student at school as necessary to discuss academic and personal issues. I also give Upward Bound permission to use the participant’s photo for advertising and social media purposes in regards to the program.
  
  By signing this, I understand that all information gathered will be kept strictly confidential and will not be communicated to any other person(s) or organization(s). I authorize the Upward Bound Program at Avila University to request and obtain these documents for as long as necessary for federal reporting purposes.
- Student's Printed Name
  
  First NameLast Name
- Student's Signature
  
  Clear
- Date
  
  MonthDayYear
  mm-dd-yyyy
- Parent/Guardian's Printed Name
  
  First NameLast Name
- Parent/Guardian's Signature
  
  Clear
- Date
  
  MonthDayYear
  mm-dd-yyyy
- The Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. § 1232g; 34 CFR Part 99) is a Federal law that protects the privacy of student education records. The law applies to all schools that receive funds under an applicable program of the U.S. Department of Education. The Upward Bound Program at Avila University will not permit access to or the release of personally identifiable information contained in student educational records to any party without the written consent of the student, except as authorized by FERPA.
- To be completed by the Student.
- 1. Please indicate your need for the program services below by marking the services you are interest in.
- 2. Rank the top 3 services listed above that you believe you are in most need of.
- 3. How much education do you expect to earn?
- 4. Please list two lifetime goals.
- 5. Please list your community and school involvement (i.e. Band, ROTC, Basketball, Theater, Church Choir, etc.)
- 6. Why do you want to be a part of Upward Bound?
- To be completed by the Student & Parent/Guardian.
  
  I certify that the information submitted in this application is true and correct to my knowledge. I further understand that any false statements may result in the loss of eligibility for the applicant’s acceptance into the program.
- Student's Printed Name
  
  First NameLast Name
- Student's Signature
  
  Clear
- Parent/Guardian's Printed Name
  
  First NameLast Name
- Parent/Guardian's Signature
  
  Clear
- Date
  
  MonthDayYear
  mm-dd-yyyy

Upward Bound Application Form