Multnomah Education Service District-UB-Application Form

Upward Bound Program Application
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Thank you for your interest in Upward Bound (UB). We will notify you by email if the student is enrolled. UB offers services to help students explore college and career opportunities and enter the college of their choice. If accepted, you will participate in workshops, educational guidance, field trips, summer programs and other activities. The Multnomah Education Service District Upward Bound Program is 100% funded by U.S. Department of Education.
Student's Name*

First NameMiddle NameLast Name
Mailing address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home phone/parent cell phone*
(999)999-9999
Student's cell phone
(999)999-9999
Student's email address*
example@example.com
Birthdate*

MonthDayYear
mm-dd-yyyy
Gender*

MaleFemaleNon Binary
(Optional) Social Security #
999-99-9999
Current Grade*

9th10th11th12th
School*
(Optional) 1. Do you consider yourself Hispanic/Latino?

YesNo
(Optional) 2. Do you consider yourself (please check all the boxes that apply)

AsianBlackHawaiian/Pacific IslanderNative American/Alaska NativeWhite/Caucasian
Is the student a U.S. citizen?*

YesNo
If not, do you have Permanent Resident status?

YesNo
Alien identification number
Is English the student's first (native) language?

YesNo
The Student is: (check all that apply) * Parents will not need to sign this document if a student indicates any of the following:*

Over 24Supporting children or dependentsMarriedCurrent or former foster careHomeless or at risk of being homelessNone of the above
Please complete the following information about each parent/guardian who currently lives with the student:
Mother/Guardian's Name*

First NameLast Name
Does the Mother or Adoptive Parent who lives with the student have a 4-year Bachelor degree from a university?*

YesNoDoes not live with the student
Check if same address as student

Check here
If not, please write your address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email address
example@example.com
Cell Phone
(999)999-9999
Emergency Phone
(999)999-9999
Father/Guardian's Name

First NameLast Name
Does the Father or Adoptive Parent who lives with the student have a 4-year Bachelor degree from a university?*

YesNoDoes not live with the student
Check if same address as student

Check here
If not, please write your address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email address
example@example.com
Cell Phone
(999)999-9999
Emergency Phone
(999)999-9999
We are required to use this information to process your application. All information is strictly confidential and is used only to determine eligibility for TRIO services. For the 2022-2023 school year, we will need your 2021 taxable income information. Your taxable income is on line 15 of your 1040 form.
Number of people living in your household*
What was your taxable family income from 2021 (found on line 15)?*

0 - $23,475$23,475 - $31,725$31,725 - $39,975$39,975 - $48,225$48,225 - $56,475$56,475 - $64,725$64,725 - $72,975$72,975 - $81,225
1. All information in this application is true and accurate to the best of my knowledge
2. I give my permission for my son/daughter to participate in all Upward Bound activities.
3. I authorize The MESD Upward Bound Program to obtain student records and documents as necessary, including grade reports, transcripts, test scores, financial aid awards, and college admission and enrollment verification. This information will be held in strict confidence and in compliance with all federal laws (FERPA) regarding confidential student information. Information collected by Upward Bound will be used for UB purposes only.
4. I authorize Upward Bound to release or obtain information from any agency or program providing supplemental services to my student.
5. I give my permission for my student’s name, photograph, work and/or statements to be used by Upward Bound for promotional, publicity, or instructional purposes.
6. I understand that to stay enrolled in Upward Bound my student is expected to be a good school citizen, make good academic effort, and fully participate in all Upward Bound activities, including an annual summer program.
7. I consent to my child using the Internet and other technology and accept responsibility for appropriate use thereof.
8. I understand that completion of this form does not guarantee acceptance in Upward Bound.
The U.S. Department of Education (USDE) requires all Upward Bound programs to track students’ progress through postsecondary education and to report this information to USDE. Upward Bound’s continued funding depends on reporting this information about UB students. We report to USDE only the student information that USDE requires.

I grant permission to the Upward Bound program and Multnomah Education Service District and its authorized representatives to furnish first aid to my son/daughter as needed, and to seek medical attention through the nearest medical facilities when students are on field trips and other authorized activities. This permission is conditioned on the understanding that in the event of serious illness or injury or the need for hospitalization and/or major surgery, UB staff will make all reasonable efforts to contact me. Failure in such efforts should not prevent UB from providing emergency treatment as may be necessary for the best interest of my child.

Several times per year, MESD Upward Bound offers field trips to local colleges, universities and technical or training institutions. MESD Upward Bound covers the transportation costs associated with these field trips as well as coordinates all activities and supervises students.

In order for your student to participate in a field trip sponsored by MESD Upward Bound, the following field trip permission slip must be signed.

I authorize this student to participate in MESD Upward Bound field trips. I understand in signing this form, I am releasing Multnomah Education Service District and TRIO Upward Bound, the director and employees thereof from all claims and demands for any harm, injury or damage which my befall my child during any field trip. I understand and agree that neither Multnomah Education Service District nor Upward Bound, the director and employees thereof may be held liable for any occurrence in connection with any field trip which may result in injury or damages to my child.

I hereby authorize Multnomah Education Service District, TRIO Upward Bound program to contact and request information from, as well as share information with the student's school, teachers, counselors and postsecondary admissions offices. I give my student, (if under 24 years of age), permission to participate in Upward Bound activities if accepted. Our signatures below indicate our commitment to the MESD TRIO program. By signing the following statement you agree that you are not receiving services from any other TRIO project.
Parent Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
"Education is the passport to the future, for tomorrow belongs to those who prepare for it today." –Malcolm X
The Upward Bound Program:
Individual Meetings: All students attend individual meetings with their Upward Bound Advisor for academic advising, career counseling and college planning. Advisors will schedule regular meetings and assign a required number of meetings. Advisors are also available at each school for meetings at the student’s request.

Monthly Class Meetings: Students attend one class meeting per month for information specific to their grade. These meetings cover information about study skills; academic requirements for getting into college; preparing for college; how to overcome obstacles on the academic record; career exploration; college exploration; and more.

Tutoring: Based on their grades, Upward Bound students may be required to attend after-school tutoring sessions. Tutors are on hand to help with math and English. Tutoring in other subjects may be available by special arrangement.

Skill-Building Workshops: Monthly workshops held at various campuses offer supplemental instruction in core subjects and school success skills. Attendance at all workshops is strongly encouraged, and may be required depending on students’ grades.

Summer Academy: The Summer Academy is a mandatory part of Upward Bound. It is six weeks long and takes place at Portland State University and Portland Community College from 9:00 am – 3:00 pm, Monday – Thursday. Fridays are field trip days. Students participate in service learning-based projects and academic seminars. Students who have previously completed the Summer Academy may have other summer options in limited circumstances; see UB Handbook for details.
The Upward Bound Senior Bridge Program:
The purpose of Upward Bound is to help students get into college. To that end, the summer after a student completes his or her senior year, Upward Bound offers the Senior Bridge Program.

The Bridge Program: For students who have graduated and are transitioning to college, Upward Bound will pay tuition and fees for approved summer courses. This is the equivalent of up to $1000 in scholarship money because it allows students to take classes that count toward their college degree free of charge.

Graduating seniors may also participate in UB college preparation including:
1. Academic Advising Sessions: This component helps students understand what to expect during the transition to college and includes tips for college success.
2. College Readiness Trips: Students will travel to the campus they will be attending in the fall to sign up for additional services; meet advisors; locate classes and residential facilities; etc.
Benefits of Upward Bound:
Students participating in Upward Bound receive significant benefits including the following:
- Opportunity to earn up to $370 per year for Upward Bound participation
- Free academic tutoring
- Laptop computer loan program for academic use
- Free field trips to colleges, cultural events and college fairs
- Free workshops to prepare for college
Working and Upward Bound:
Many working students participate in Upward Bound year-round. Working should not keep you from being in UB. Most employers are happy to support your opportunity to be in this program. Part of your commitment to Upward Bound is to talk to your employer ahead of time to make arrangements to work later in the day or on weekends during the summer sessions, or to attend field trips. Please discuss this with your parents and the Upward Bound Advisor if you have any concerns about working and UB.
Upward Bound Student & Parent Agreement
Can you commit to all parts of the program?*

YesNoUnsure
Please list any questions or state potential conflicts you may have.
Student signature:

Clear
Date

MonthDayYear
mm-dd-yyyy
Parent signature:

Clear
Date

MonthDayYear
mm-dd-yyyy

Upward Bound Program Application

Please complete the following information about each parent/guardian who currently lives with the student:

The Upward Bound Program:

The Upward Bound Senior Bridge Program:

Benefits of Upward Bound:

Working and Upward Bound:

Upward Bound Student & Parent Agreement