Virginia Highlands Community College-UB-Application Form

Upward Bound
Upward Bound is a federally funded program designed to motivate young people and help them develop the academic skills needed for success after high school.

The Virginia Highlands Community College program offers a variety of services to high school students during the academic year, including academic and career counseling, cultural enrichment activities and travel, tutoring, and personalized
educational planning. A summer program comprised of collaborative learning projects is offered on the VHCC campus.

High school students between the ages of 13 and 19 are eligible to participate in the Upward Bound Program at VHCC if they are:
- A first-generation college student. This means that neither parent earned a four-year college degree, or
- Classified as low income. To qualify, your annual taxable income must not exceed 150% of the poverty level as defined by the U.S. Department of Education.
High School Meetings • during the Academic Year

Upward Bound Counselors meet with students each week at their high school and provide academically focused workshops and activities. These workshops are designed to help students excel in their current classes and prepare for college. An occasional Saturday session may also be held on the VHCC campus.

Additionally, college visits and other cultural enrichment trips are planned throughout the year for program participants. These may include visits to museums, historical sites, sporting events, theater performances, and other
locations that provide opportunities for students to learn more about the world around them.

Summer Program • on the VHCC Campus

The four-six week summer program provides the perfect opportunity for students to become familiar with the VHCC campus and its faculty while participating in collaborative learning projects. Transportation is provided each day. The
goal of the summer program is to provide hands-on activities that teach students organizational, leadership, and research skills, plus time management and project development skills.

Contact Information

Director • Leigh Ann Adams, ladams@vhcc.edu or (276) 739-2506
Academic Coordinator • Stacey Dorton, sdorton@vhcc.edu or (276)739-2507
Administrative Assistant •Ella Ratcliffe, eratcliffe@vhcc.edu or (276) 739-2564

Individual Services

Tutoring and Academic Counseling are available throughout the year for any student in need.

Incomplete Applications will not be considered
Legal Name*

First NameMiddle InitialLast Name
Preferred Name

First NameLast Name
Social Security Number*
999-99-9999
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County of Residence (Check One)*

WashingtonSmythBristol City
School*
Current Grade*
Parent Phone (Cell)
(999)999-9999
Parent Phone (Home)
(999)999-9999
Do you send/receive texts?

YesNo
Student Phone (Cell)
(999)999-9999
Do you send/receive texts?

YesNo
Parent Email:*
example@example.com
Student Email:*
example@example.com
Birthdate*

MonthDayYear
mm-dd-yyyy
US Citizen?*

YesNo
Request for Program Services- Please check the services you are most interested in receiving from the VHCC Upward Bound Program:*

Academic TutoringCollege Field TripsSAT/SOL PreparationAcademic CounselingCollege Admissions HelpCareer AwarenessEducational PlanningFinancial Aid AssistanceCultural Field Trips
Family Information- With whom do you live?*

Both ParentsOne ParentFoster FamilyLegal GuardianOther
Mother’s Name

First NameLast Name
Daytime Phone
(999)999-9999
Father’s Name

First NameLast Name
Daytime Phone
(999)999-9999
Guardian’s Name (If not a parent)

First NameLast Name
Daytime Phone
(999)999-9999
Please list your brothers and/or sisters with their ages and current grade levels:
Name

First NameLast Name
Age
Grade
Name

First NameLast Name
Age
Grade

Current Grades*

	Please list your classes and the grade you received on your most recent report card.
1.
2.
3.
4.
5.
6.

High School Curriculum:*

	Please rank the following academic areas 1-5 (1 indicates your highest interest)
math
science
history
English
foreign language

Please indicate the type of high school diploma you plan to complete. (To be successful in the VHCC Upward Bound Program, it is recommended that students enroll in college preparatory classes.)*

Prescribed Studies/21 Credits Standard DiplomaAdvanced Studies/23 credits Governor’s Seal Diploma

Extracurricular activities and honors

	Please list your extracurricular activities and honors
1.
2.
3.
4.

Education Plans: Upward Bound is designed to help students achieve academically and enter the college or university of their choice. Please check the statements below that best describe your educational plans.*

I am undecided about my educational goals.I have no plans to continue my education after high school.I plan to enter the military.I plan to attend a state supported college or university.I plan to attend a state supported community college.I plan to attend college or university out of state.I plan to attend a private school in Virginia.

College choices

	Please list 4 college choices
1.
2.
3.
4.

Career Plans

	Please list four careers that currently interest you.
1.
2.
3.
4.

The VHCC Upward Bound program is funded by the US Department of Education to raise college entrance and graduation rates in Smyth County, Washington County and the City of Bristol. This is a year-round educational experience. Upward Bound students are required to attend scheduled Upward Bound classes and/or weekly workshops, participate in program travel, attend after-school tutoring and participate in the six-weeks summer program held on the VHCC campus.
Student’s Signature*

Clear
Date

MonthDayYear
mm-dd-yyyy
Demographic information: (For Research/Reporting only)
Gender*

MaleFemale
Race*

Hispanic or Latino (of any race)American Indian/Alaskan NativeAsianBlack/African AmericanWhite2 or more racesNative Hawaiian or other Pacific Islander
Eligibility Form

Parents’ Educational Completion
Mother’s Name*

First NameLast Name
Educational Completion (Check One)*

Grades 1-89101112Certificate2-Year Associates4-year Bachelors
Father’s Name*

First NameLast Name
Educational Completion (Check One)*

Grades 1-89101112Certificate2-Year Associates4-year Bachelors
Income Documentation

Income documentation is required to ensure student meets federal guidelines. In case of divorce, please list the parent who claims the student on their federal income tax
Is the Student in Custody of State of Virginia?*

YesNo
(If yes, income information not required)
How many people live in your household? (include children away at school) *
Please enter your TAXABLE INCOME from your most recent tax forms - DO NOT USE ADJUSTED GROSS INCOME for this report*
Line 11b- Form 1040
If you do not file an income tax form, please indicate your most recent income below:
Wages, Salaries or Tips
Black Lung Benefits
Business or Farm Income
Unemployment
Social Security Benefits
My signature below indicates to the best of my knowledge, that the information provided on this form is true, complete, and accurate. I hereby authorize the VHCC Upward Bound staff to obtain copies of my child’s academic and financial assistance records from the education institution he/she is now attending and from education institutions attended in the future.
Parent or Guardian Signature*

Clear
Date

MonthDayYear
mm-dd-yyyy
Student Signature*

Clear
Date

MonthDayYear
mm-dd-yyyy
Program Funding: The Upward Bound Program is funded through a $362,000 annual grant from the US Department of Education under Title IV (The Trio Programs) of the Reauthorization of Higher Education Act. All services are free to qualifying individuals. The Upward Bound Program at VHCC is authorized to serve 65 students in select schools in Washington County, Smyth County, and the city of Bristol, Virginia.

Virginia Highlands Community College promotes and maintains educational opportunities without regard to race, color,sex, ethnicity, religion, gender, age (except where age is a bonafide occupational qualification), disability, national origin,or other non-merit factors. This institution prohibits sexual harassment including sexual violence.

Upward Bound