Bevill State Community College-Fayette-UB-2023 Application Form

Form
Information must be completed for at least ONE custodial parent/guardian.

Personal Information (Part 1)
Name*

First NameMILast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number*
(999)999-9999
Student Cell Number
(999)999-9999
Age*
Birthdate*

MonthDayYear
Date
Gender*

MaleFemale
Are you a citizen of the United States?*

YesNo
If No, Permanent Resident I.D Number
Student's Email*
example@example.com

Family Information
Parent/Guardian 1*
Employer/Occupation*
Work Phone Number*
(999)999-9999
Email*
example@example.com
Does this parent have a 4-year college degree?*

YesNo
Parent/Guardian 2
Employer/Occupation
Work Phone Number
(999)999-9999
Email
example@example.com
Does this parent have a 4-year college degree?

YesNo
Are you now receiving or have received services from another TRIO program? (ETS, Gear-Up)
Are you now receiving or have received services from Upward Bound?
If so, who?

Educational Information
School*

Aliceville High SchoolHubbertville High SchoolBerry High SchoolLamar County High SchoolFayette High SchoolPickens County High SchoolGordo High SchoolSouth Lamar High SchoolWinfield High School
Current Grade*
Current Culmulative GPA*

New Federal Census Guidelines
Ethnicity*

Hispanic/LatinoNon-Hispanic
Race: If Not Latino, Check One*

American Indian or Alaskan NativeNative Hawaiian or Pacific IslanderAmerican-IndianWhite/CaucasianAsianTwo or More

Student Parent Contract
In order for us to serve you with a strong academic, cultural, and collegiate program, we must have sincere commitment from you. Please carefully review the following:

I understand that during my participation in Upward Bound:

1. My goal will be to complete high school and pursue post-secondary education

2. I will maintain at least a 2.50 GPA in high school

3. I will accept appointments and attend all meetings arranged by my Upward Bound advisor

4. I will participate in all required Upward Bound and Bevill State Community College

5. I will abide by all rules and regulations of Upward Bound and Bevill State Community College

6. Poor attendance or lack of participation will be a basis for dismissal from Upward Bound

In addition to the application data given here, we will need to obtain information from other sources to sufficiently meet the academic needs of our students and the reporting requirements of the U.S. Department of Education. We gather information from high schools, colleges, testing institutions, and other agencies or universiies on behalf of our students and program. Your signature at the bottom of this form authorizes Upward Bound to:

1. Request a copy of your middle/high school and/or college transcripts and test scores from your school

2. Request a copy of your SAT and/or ACT test scores

3. Use your Social Security Number to request a copy of your financial aid application, transcripts, college enrollment status and awards from the federal &state funding agencies, post-secondary institutions, and national Student Clearinghouse (when admitted to the program)

4. Communicate with representatives from agencies & post-secondary institutions on your behalf

I hearby authorize Upward Bound to contact and request information from, as well as to share information with, the above mentioned parties. I give my son/daughter permission to participate in Upward Bound activities if accepted. Our signatures below indicate our commitment to the Upward Bound Student and parent Contract.

To the best of my knowledge, all the information I have provided in this application is true.
Print Student's Name*
Student's Signature*

Clear
Print Parent's Name*
Parent's Signature*

Clear
Print Parent's Email*
example@example.com
I give permission for my son/daughter to be interviewed, photographed or videotaped by Upward Bound for use on radio, TV, in printed news media, or in program promotional materials and documentation.*

YesNo
Statement of Confidentiality

The information in the application is confidential according to the Family Rights and Privacy Act. The U.S. Department of Education has the authority to gather the information requested in the application (20 USC 1231a). The only persons authorized to examine the contents of this application are the students, their parents, employees at the school attended, and the authorized Upward Bound staff.

Upward Bound Student Needs ASsesment

Academic Needs*

	Strong Need	Some Ned	No Need
1. To learn how to complete and turn in my homework on time.
2. To get better grades in school.
3. To take tests better and with less anxiety.
4. To organize my time, activities, and responsibilities better.
5. To learn more about high school requirements for college.
6. To listen better in class and ask more questions.
7. To relate to and communicate better with my teachers.
8. To identifiy, set and evaluate goals for the future.

Personal Needs*

	Strong Need	Some Ned	No Need
1. To better understand my parents and other adults
2. To learn to deal with conflict in a positive manner.
3. To be more accepting of my physical appearance.
4. To learn how my self-esteem affects my behavior.
5. To learn how to get along better with my peers.
6. To learn to accept people who are different from me.
7. To learn more about the use/abuse of drugs and alcohol
8. To accept greater responsibility for my actions.

Career and Post-Secondary Needs*

	Strong Need	Some Ned	No Need
1. To explore variety of career opportunities.
2. To learn about job applications, resumes, and interviews.
3. To learn more about the postsecondary admissions process.
4. To prepare for exams like the PSAT, ACT or SAT.
5. To visit more colleges.
6. To learn about college costs and how to pay for college.

Please list at least one college or university you are interested in visiting.*

Student Questionaire
What do you think will be expected of you as an UPWARD BOUND student & how can you contribute to the program?*
What do you think is the function of the UPWARD BOUND Project & how do you expect UB to help you?*
Why should UB choose you as a participant over other qualified applicants?*
Write a paragraph describing your educational and career goals and how you plan to achieve those goals over the next ten years.*
Are you able and willing to attend one monthly Saturday session during the academic year?*

YesNo
Are you able and willing to attend the six-week summer program?*

YesNo