Higher Education Consortium Of Metropolitan St.-UB-Application Form

Higher Education Consortium of Metropolitan St. Louis

Upward Bound Program

Higher Education Consortium
Upward Bound Program
St. Louis Community College
William J. Harrison Education Center
3140 Cass Avenue
St. Louis, Mo 63106

Upward Bound is a college preparatory academy which provides high school students the opportunity to acquire the academic skills and personal motivation necessary to finish high school, enter and earn a degree from a college or university. The students and parents selected for HEC Upward Bound must have the desire, determination and commitment to participate in all activities and training.

The mission of The Higher Education Consortium of Metropolitan St. Louis (HEC) is to enhance students’ access and achievement in higher education. HEC Upward Bound is designed to help students improve their academic performance and prepare them to enroll and graduate from a college or university of their choice. HEC Upward Bound is housed in the William J. Harrison Center at St. Louis Community College.

Program Requirements

HEC Upward Bound is a federal funded educational program. The Federal Government sets the guidelines for edibility. To be eligible for Upward Bound, a student must meet U.S. Department of Education taxable income guidelines.

Federal Income Guidelines

Size of Family Unit	48 Contiguous States, D.C.
1	$20,385
2	$27,465
3	$34,545
4	$41,625
5	$48,705
6	$55,785
7	$62,865
8	$69,945

Additionally, HEC Upward Bound students must meet the following requirements:

Be first generation college bound (neither parent living in home has four year degree)
Be taking a college prep curriculum
Have a 2.5 G.P.A in high school
Display potential to succeed at the postsecondary level
Attend a SLPS target school or live in the surrounding area
Participants should participate in all services and activities

Benefits of being an Upward Bound student

The Academic Component begins in October and runs to May. Students take classes that will provide additional academic support and development on two Saturdays of each month at St. Louis Community College at Forest Park. Students receive tutoring, ACT/SAT preparation, personal and career guidance, assistance with financial aid and college admissions process.

The Summer Component is a six-week educational program. Students attend academic classes on the campus of St. Louis Community College- Forest Park and participate in fine arts, recreational, ad cultural activities. The summer concludes each year with a college tour where student’s travel to selected cities’ to get information, tour campuses, interact with college students and gain a better understanding about college life.

Section IV: Sign and Submit
Student Agreement
Upward Bound Student Agreement

If accepted to the program, I, , agree to attain all personal, academic, and career goals that TRiO Upward Bound staff and I have set. I agree to the following:

A) Regularly attend Saturday Academy, workshops and activities.

B) Complete supplemental paperwork (parent/guardian permissions are required)

Please submit all documentation within 15 days of this form

Stipends are not paid out until after 60 days of enrollment

C) Provide a counselor/teacher recommendation

D) Maintain a 2.5 G.P.A. every semester

E) Maintain acceptable school behavior

Students, after you sign below click SAVE and provide your parent's email address so that we can send them this application for a signature.

Parents after signing this form, you will recieve a call from a member of our staff to schedule and interview.
Date

MonthDayYear
mm-dd-yyyy
I hereby certify that all the information on this application is true and correct to the best of my knowledge. This includes my declaration of income and household size. I understand that all of the information on this application is confidential and will be used for program recording, tracking, and reporting as required by the U.S. Department of Education. I give HEC TRIO UpWard Bound the right to reproduce, distribute, transmit, publish, display, in whole or in part, either digitally or in any other medium and use my child's name and/or photographic image. I permit HEC TRIO Upward Bound staff access to my child’s, academic, attendance and discipline records from his/her current school, including St. Louis Public Schools pursuant to its memorandum of understanding with St. Louis Public Schools, and grant access to information regarding college enrollment, attendance and completion via The National Clearing House. Finally, within the next 30 days, I agree to complete supplemental forms including, but not limited to field trip permissions, medical information, direct deposit form for stipend, etc for my child to be eligible for the full benefits of the program. I understand that If I am interested in my child participating in Summer Academy, then I agree to complete the supplemental forms within the next 10 days or prior to the start of Summer Academy whichever comes first.
We want to get to know you. Upload a photo!

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Upload Your Transcripts from Tyler SIS

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Student Signature (Please sign and click "send to parent" if parent is not present).

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Parent Signature (Student is not eligible without parent/guardian signature).

Clear
Date

MonthDayYear
mm-dd-yyyy
Telephone Number:*
(999)999-9999
Social Security #:
999-99-9999
Age:
Sex:F*

MaleFemale
U.S. Citizen:

YesNo
If NO, USCIS/DOCUMENT #
Student ID #
School, community, or volunteer activities:
Do you currently or have you previously participated in Upward Bound or another TRiO Program? If so, whatprogram/when/where?
How do you prefer we contact you, the student (Check all that apply)

Email Parent GuardianEmail StudentCall Parent/GuardianCall StudentText Parent/GuardianText Student
Work/Cell Phone:
(999)999-9999
Work/Cell Phone:
(999)999-9999
HEC Upward Bound received funding from the U.S Department of Education. It is required that the staff verifies student eligibility by obtaining income documentation. This documentation is extremely important in order for us to consider a student’s eligibility into the program. All information is kept confidential. Thank you.
Did student’s mother graduate from a four-year college/university?

YesNo
Did student’s father graduate from a four-year college/university?

YesNo
Number in Household:
Annual Family Income:
Parent/ Guardian 1 Employer:
Telephone Number:
(999)999-9999
Parent/ Guardian 2 Employer:
Telephone Number:
(999)999-9999
I certify that the information provided is true and correct, to the best of my knowledge.
Parent/ Guardian Signature 1:*

Clear
Date:*

MonthDayYear
mm-dd-yyyy
Parent/ Guardian Signature 2:*

Clear
Date:*

MonthDayYear
mm-dd-yyyy
PERSONAL ESSAY
NAME:

First NameLast Name
SCHOOL:
The personal essay is an important part of the selection process. In 100 words or more, describe your educational and career goals, reasons why you want to be in HEC Upward Bound, and what you hope to get out of the program. Please indicate any additional information you would like us to consider.
Signature of Student*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Student Name

First NameLast Name
I understand that my child, {studentName}, may have the opportunity to participate in field trips sponsored by HEC Upward Bound under the direction of a staff member(s) and/or program director. I request that my son/daughter be allowed to attend such field trips. I give my permission for my son/daughter to be allowed to attend such field trips. I give my permission for my son/daughter to be transported to these field trips in vehicle owned or contracted by HEC Upward Bound that may be driven by staff member (s).

I hereby waive any claim against HEC Upward Bound, their agents, representatives, and employees from all claim, damages, or other liabilities or injuries to my son/daughter sustained in connection with any such field trip. If the program director or staff member participation in this event deem in necessary to seek emergency medical treatment for my son/daughter, I grant permission for my child to be treated at a nearby medical facility. I understand that I am responsible for all medical and hospital expenses incurred by my child and represent that I have adequate insurance or means to cover such expenses.
Please Print Name

First NameLast Name
Parent or Legal Guardian Signature*

Clear
Date:*

MonthDayYear
mm-dd-yyyy
Telephone number:
(999)999-9999
I give permission to HEC Upward Bound Program the right to reproduce, distribute, transmit, publish, display, in whole or in part, either digitally or in any other medium used my child’s name and/or photographic image. I agree that such reproduction of picture/video may be edited as desired and used in whole or in part in the activities of HEC Upward Bound. I release and discharge HEC Upward Bound and its agents, representatives and assignees from any claim or cause of action now known or later discovered, for among other things, invasion of privacy, right of publicity, and defamation arising out of the use and utilization of the photographs.
Parent/ Legal Guardian's Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
We (student and parent/guardian) agree to utilize campus computer labs for the purpose of completing classroom assignments. We understand that access to the computer lab and resources is contingent upon responsible use. Any inappropriate use of the Internet or other computer programs, services, and facilities may result in loss of privileges. Legal or disciplinary action will be pursed for violation of these codes per college procedure.
Student Signature:*

Clear
Date:*

MonthDayYear
mm-dd-yyyy
Parent/ Guardian Signature:*

Clear
Date:*

MonthDayYear
mm-dd-yyyy
Student's Name:

First NameLast Name
Date of Birth:

MonthDayYear
mm-dd-yyyy
Is the student covered by any medical insurance?

YesNo
If “Yes” please complete the following:
Insurance Provider:
Policy Number:
Name of Family Physician:

First NameLast Name
Office Telephone #:
(999)999-9999

Please list any personal or family medical history that may be or importance to our records, including allergies and physician prescribed medicine that the student is currently taking:

	List Medication/ Medical History	Allergies/ Allergic Reaction	Diagnosis
1.
2.
3.
4.

As the parent/guardian of the above named student, I hereby authorize the HEC Upward Bound Director and his/her authorized staff to use local and/or out-of-town hospitals and clinics for the treatment of illness or accident to my daughter/son. I further authorize HEC Upward Bound to select a licensed physician or surgeon for necessary treatment. Secondly, I authorize HEC Upward Bound Director and/or staff member to render such information required by the hospital admission rules and to sign, as a competent adult, forms permitting examination and possible treatment. HEC Upward Bound regents and employees shall not be liable in any way for any consequences from said diagnosis, medical and/or surgical treatment and are hereby released from any and all claims and causes of action that may arise out of such diagnosis, treatment or surgery to the extent allowed by law.

In case of sudden illness or accident, I consent to emergency treatment by the professional medical/nursing staff. In case of serious illness/accident, I will be notified immediately, but if I cannot be reached, necessary interim emergency care may be provided. I understand HEC Upward Bound staff will contact those individuals listed in case of an emergency.

In Case of an Emergency, I hereby request that the following individual(s) be contacted:*

	Name	Relationship	Telephone #
1.
2.
3.
4.

Parent/ Legal Guardian Signature :*

Clear
Date:*

MonthDayYear
mm-dd-yyyy
Best Telephone Number to Call: 1.
(999)999-9999
Best Telephone Number to Call: 2.
(999)999-9999
My Child’s Attendance
Describe, in a few words, why you want your child in Upward Bound
Parent Name

First NameLast Name
Student Name

First NameLast Name
I, {parentName} the parent of {studentName95} will ensure that my child attend HEC Upward Bound on two Saturdays of each month from October through May. My child will also attend tutoring if offered at his/her school. I understand that if my child misses more than two consecutive Saturday Academy Sessions they may risk losing their space in the program.
Parent Assembly Attendance
Parent Name

First NameLast Name
I, {parentName98} commit myself to attending the monthly Parent Assembly throughout the academic year. I understand that I play a vital role in my child’s education and my child’s space in HEC Upward Bound may be contingent of my not missing more than one Parent Assembly. I will communicate with HEC Upward Bound staff regarding difficulty I may be experiencing that may prevent my attendance.
Parent/ Legal Guardian Signature:*

Clear
Date:*

MonthDayYear
mm-dd-yyyy
Student's Name:

First NameLast Name
I hereby authorize the high school that my child attends and/or St. Louis Public Schools to release the following information necessary for compliance with the United States Department of Education annual Performance Report and to chart student academic progress:
- Standardized test scores
- Transcripts
- Report card grades
- End of course scores
- Attendance
- Information pertaining to student academic progress
The Upward Bound Staff (Director, Education Counselors/Specialists and Tutors) also has permission to visit the school to meet with the above names student.
Signature of Student*

Clear
Student ID #
Signature of Parent/Guardian*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Important Things to consider for admittance into HEC Upward Bound:

· You can upload your transcripts and grade reports during the application process

· A teacher or counselor recommendation is required.

· Government proof of income can be uploaded by parents/guardians during the application process.

· Stipends are paid monthly by direct deposit. Current bank information is required. If you do not have an account, we can help you establish one with PNC Bank. Visit them online or stop by any branch to open a Virtual Wallet account.

· You may participate in Upward Bound programing; however, stipends will be held until all documentation is submitted. If documents are not submitted within the 15 days of application, you may still participate, but will not be eligible to receive your stipend until all requirements are met.

For any questions, please contact an Upward Bound staff member:

o Ms. Jabar at rjabar@hecstl.org or 314-648-4159

o Mr. Todd at ktodd@hecstl.org or 314-810-2485

Higher Education Consortium of Metropolitan St. Louis

Parent/Guardian Contact Information

Completed by Parent/Guardian

Student Agreement