Indiana Wesleyan University-UB-2023 Application Form

Application Form
To Whom It May Concern,

Thank you for your interest in Upward Bound. Your next step is to fill out the application on our website or contact our office to schedule a time to fill out the application in person.

The following items need to be submitted with the application for it to be processed:
- Birth Certificate
- Social Security
- Current transcript from High School
- State Test Results (ISTEP and/or NWEA)
- Essay (3 Paragraphs)
Any documents not submitted with the application will cause a delay in the application process. Application cannot be review until completed with all documents submitted.

After Upward Bound staff review your application and documents, they will reach out via phone to confirm the information and give a date and time that your student will be interviewed. if your student attends Marion or Mississinewa High School, the interview will happen during schoo hours. If your student attends another Grant County School, then interview will be scheduled at our office located on Indiana Wesleyan Campus in the Barnes Student Center Suite 284.

If you have any questions, please feel free to contact the Upward Bound office by phone at 765-677-2935, or by email at upwardbound@indwes.edu.

We look forward to meeting you!

Upward Bound Staff
Date*

MonthDayYear
Date
Student's Full Legal Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*

FemaleMale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Email Address*
example@example.com
Phone number:*
(999)999-9999
Phone*

MobileHome
High School*
Grade Level*

9101112
Are you a citizen of the United States?*

YesNo
If no, are you a permanent resident of the US?*

YesNo
Are you a participant in the 21st Century Scholars Program?*

YesNo
Ethnic/Racial Identity*

American Indian/Alaskan NativeAfrican American/BlackEuropean American/WhiteHispanic/LatinoMulti-ethnic/Multi-racialNative Hawaiian/Pacific IslanderOther
What is your school website login information*

PowerschoolSkywardSycamoreInfinite
User ID*
Password*
Have you determined what your plans are for after high school graduation?*

YesNo
If so, what have you considered?*
What colleges are you interested in attending?*
School Recommendations: Please list your school counselor and a teacher, we will reach out to them
Counselor Name*
Email*
example@example.com
Teacher Name*
Email*
example@example.com
Why are you interested in the Upward Bound Program and how will it benefit you?*
Essay - Please write a 3 paragraph essay about a difficult, challenging or exciting experience you have had. Describe how you felt and what you learned from that experience. Essays should be the original work of the student applying for the program.*

Family Financial Information
Did parents complete an Income Tax Return for last year?*

YesNo
What was your total taxable income for last year? (NOT adjusted gross income)*
Does the family receive any type of public assistance?*

YesNo
Type*
Please explain any income not listed above (disability, child support, etc.)*
How many persons were dependent upon the family household income for this past year?*

Please list ALL individuals currently living in the student's household (whether they are related or unrelated)*

	Name	Age	Relation to Student
1
2
3
4
5
6
7
8

I fully support my child's application for admission into the IWU Upward Bound program. I certify that all the information reported on this form, including all financial information, is true and correct to the best of my knowledge.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date

Financial Sheet
I, __________, certify that I meet the low-income guideline based on the chart below, and that all information reported regarding last year's household income is true and accurate.*
Federal TRIO Programs Current-Year Low-Income Levels

(Effective January 19, 2023 until further notice)

Size of Family Unit	48 Contiguous States, D.C, and Outlying Jurisdictions	Alaska	Hawaii
1	$21,870	$27,315	$25,155
2	$29,580	$36,960	$34,020
3	$37,290	$46,605	$42,885
4	$45,000	$56,250	$51,750
5	$52,710	$65,895	$60,615
6	$60,420	$75,540	$69,480
7	$68,130	$85,185	$78,345
8	$75,840	$94,830	$*7,210

For family units with more than eight members, add the following amount for each additonal family member: $7,710 for the 48 contiguoug states, the District of Columbia and outlying jurisdictions; $9,645 for Alaska; and $8,865 for Hawaii

The term "low-income individual" means an individual whose family's taxable income for the preceding year did not exceed 150 percent of the poverty level amount.

The figures shown under family income represent amounts equal to 150 percent of the family income levels established by the Census Bureau for determining povert status. The poverty quidelines were published by the U.S. Department of Health and Human Services in the Federal Register on January 19,2023 and are effective as of January 19, 2023.
Total 2022 Household Income Amount*
Signature*

Clear
Date*

MonthDayYear
Date

Release of Liability, Assumption of Risk, Media and Medical Authorization
Name of Student*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Emergency Contact 1*
Relation*
Phone*
(999)999-9999
Emergency Contact 2*
Relation*
Phone*
(999)999-9999
Release of Liability

In consideration of being permitted to voluntarily participate in the Upward Bound ("Upward Bound") program at Indiana Wesleyan ("IWU"), I release, or give up, any legal claim that I might have against IWU, its Board of Trustees, officers, employees, agents, and volunteers, whether caused by negligence or otherwise, to the fullest extent permitted by law. This release is binding on my legal representatives or anyone who tries to claim through me. If anyone listed above is sued or has to pay anyone else because of my conduct. I will reimburse them for their legal costs, fees, and payments.

Assumption of Risks

Upward Bound programming includes numerous activities ("Activities") involving inherent risks. Activities may include but are not limited to the following: intrastate travel, visitations on educational institutions, travel to museums, theatres, sporting events, businesses, cultural and nature exhibits, and other points of interest. During these Activities, students may be exposed to inclement weather, adverse reactions, to plants, insects, and animals, transportation risks (including driver error), food/beverage allergies, and other unforeseen risks.

Other Activities on IWU's campus may include, but are not limitede to, team and individual sports competitions, swimming, climbing, exercising, weight training, using rope courses, dodgeball, using various sports and exercise equipmentm and other athletic activities involving physical exertion. Risks include, but are not limited to, collisions with other participants and objects, head, neck and spine injuries, concussions/traumatic brain injury, slips, trips, and falls, muscle, joint, ligament, tendon, lime, and bone injury, abradions, contusions, and lacerations, cardiovascular complications, allergic reactions, lost wages, loss of major life activities, other physical, mental, and emotional injuries, and loss of life.

I understand these risks and hereby assume and acceot all risks of injury or damage while participating in these Activities. I represent to IWU that I have the skills and ability to safely participare in these Activities and that any equipment that I furnish is in good condition, order, and repair and is fit for and will be used for its intended purpose. I do hereby declare my self to be physically sound and suffering from no condition, impairment, disease, or other illness that would prevent or inhibit my participation in these Activities.

Media and Internet Release

I hereby grant IWu full and absolute permission and all rights to copyright, publish, display, and use for any legal purpose all images and descriptive text or statements in which my child may appear. I hereby grant permission for my child to access networked computer services such as the Internet, World Wide Web, and if applicable, electronic mail at IWU

Medical Authorization/Consent

I certifiy that I have adequate insurance to cover injury or damage, including damage or loss to personal items, that I may cause or suffer while participating in these Activites, or else I agree to bear the cost of the injury, damage, or loss myself. I consent to the provision of emergency medical treatment to the extent that the treatment is necessary in the opinion of a medical professional, knowing I am responsible for paying all costs of medical care.
Health Insurance Company *
Member ID#*
Policyholder's Name*
Relationship to Participant*
Medical Disclosure and Authorization- Please note any special medical considerations regarding student's health (medications, allergies, injuries, etc.) Please list any prescriptions:*
Allergies*
Injuries*
Other Info*
IWU may give over-the-counter medication to my child (Such as Tylenol, Ibuprofen, and Antacids)*

YesNo
I have this Release and Authorization Form, I understand it, I agree to its terms and conditions, and by signing below, I hereby give permission for the Student to participate in Upward Bound Activities.
Printed Full Name of Parent/Legal Guardian*

First NameLast Name
Signature of Parent/Legal Guardian*

Clear
Date*

MonthDayYear
Date

School Records Release Form
Printed Name*

First NameLast Name
Date of birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I acknowledge that the purpose of the Indiana Wesletan University Upward Bound program is to prepare me/my child to successfully graduate from highschool and a four-year post-secondary institution of higher education.

As a federally-funded program, Upward Bound must abide by the U.S. Department of Education's rules and regulations in regards to tracking current and former Upward Bound students [Authorization: U.S. Department of Education: 34 DFR Part 645.32(b)(4) and (b)(5)].

As such, I/we understand the obligation of Upward Bound to obtain acadmeic documentation from a current or previous high school(s) as well as documentation of post secondary enrollment for six years following high school graduation.

These records may include, but are not limited to the following:
- Transcripts and grade reports
- Class Schedules
- Scores for standardized achievement and diagnostic tests/assessments
- Attendance data
- Individualized Education Programs
- Other reports or acadmeic data necessary for admission and participation in IWU's Upward Bound program.
Therefore, we authorize the release of these records to IWU's Upward Bound office for the period of the student's school attendance from 8th grade through high school and for six years following high school graduation. We also give authorization for IWUs Upward Bound Office to utilize the username and passowrd listed below for the online student record system for purposes of tracking academic information.
Student's Signature*

Clear
Date*

MonthDayYear
Date
Parent/guardian Signature*

Clear
Date*

MonthDayYear
Date

Citizenship & Dependency Verification
As the parent/guardian of ____________ (referred to as the student), I, ______________ certify that the student is a citizen of the United States. I have a furnished copy of his/her Birth Certificate and Social Security card to the Indiana Wesleyan University Upward Bound Office as evidence of United States citizenship.

I also certify that the student is a dependent in my househould. As my dependent, I procide for his/her care and claim or could claim him/her as a dependent for IRS tax purposes.
Name of child (please print)*

First NameLast Name
Name of parent(s)/guardian (please print)*

First NameLast Name
Signature of parent/guardian*

Clear
Date*

MonthDayYear
Date
Upload Birth Certificate

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Upload Social Security Card

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Upload Current Transcript

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Upload State Test Results ( PSAT, ASVAB, ISTEP, and/ or NWEA)

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