Purdue University-Northwest-UB-Application Form

TRIO UPWARD BOUND PROGRAM APPLICATION

Purdue University Northwest: Hammond Campus
2200 169th St., Hammond, IN 46323 | Classroom and Office Building Room 176

Phone: 219.989.2392- pnwupwardbound@pnw.edu
Visit our web page at www.pnw.edu/upward-bound

Mission: The Upward Bound Program is dedicated to providing low-income, firstgeneration high school students with the motivational and educational skills necessary for a successful post-secondary education.

PLEASE BE ADVISED THAT UPWARD BOUND IS A YEAR-ROUND PROGRAM THAT INCLUDES SATURDAY CLASSES DURING THE ACADEMIC YEAR FROM SEPTEMBER THROUGH APRIL AND A SUMMER COMPONENT FROM JUNE THROUGH AUGUST. STUDENTS ARE EXPECTED TO PARTICIPATE IN ALL COMPONENTS.

Submit the completed application to the Upward Bound Office located at the
Classroom and Office Bldg. in Room 176. The information contained in this application is for the purpose of determining the applicants eligibility for the Upward Bound Program. All information received is confidential.

PLEASE MAKE SURE YOU COMPLETE EVERYTHING LISTED ON THIS CHECKLIST. YOUR APPLICATION WILL NOT BE CONSIDERED UNTIL IT IS COMPLETE.

Checklist:
- Part I: General Student Information with applicant signature
- Part II: (a) Family Information, Education
- Part II: (b) Family Information, Financial Eligibility
  - Federal tax return (Dependent must be listed on the return.)
- Part III: Letter of Recommendation Forms
  - Math/ Science or English Teacher
  - Counselor
- Part IV: Academic Records Release Statement
- Part IV: Most Recent High School Transcript (Copy of 8th Grade Transcript for 9th grade only)
- Part IV: State Standardized Test Scores (if not shown on transcript)
Please return your completed application to the Upward Bound main office or to your Guidance Counselor’s office and Upward Bound staff will pick it up. Please email pnwupwardbound@pnw.edu and let us know where you have dropped of your application if left with your Guidance Counselor. Include your first and last name, grade, and school you attend. Do not email or fax your application.
Program Application Instructions

1) Please PRINT in black or blue ink or type your response and consent. Leave no blank space.
2) Applicants must provide a copy of the most most current High School transcript,
grade report, and ISTEP test scores. These documents must accompany the
application.
3) Parents, please submit with this application, documentation of your family’s income.
The following are acceptable forms of documentation:

- A signed copy of your family’s federal tax forms (Forms 1040, 1040-A)
- Proof of eligibility letter from a caseworker or public assistance agency that
verifies the families level of income or assistance
- A Social Security or Veterans benefit award letter

4) After all application materials are received, someone from the Upward Bound office will contact each student to arrange an introduction meeting. Introduction meetings allow Upward Bound Staff to verify information provided in the application as well as provide the opportunity for parents and students to gain further insight into program expectations and activities.
5) Please complete the student information on the enclosed Counselor, Mathematics, English, and Science teacher comment forms. (ALL FORMS SHOULD BE RETURNED FOR THE APPLICATION TO BE CONSIDERED COMPLETE)

All Summer Components are Mandatory and are Hybrid (Residential and Non-residential)

Starting second week of June and can go up until the first week of August

Part II (a) – Family Information, Education
To be completed by the parent(s) or legal guardian of the student applicant

Federal eligibility requirements for the Upward Bound Program require each applicant to be a Firstgeneration college student and/or low income. A first-generation college student is defined as a student where neither parent has earned/received a Bachelor’s degree from a college or university.

Please list below ONLY those who are currently living with the applicant and providing financial assistance.
Parent/Guardian #1 Name:*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone:*
(999)999-9999
Cell Phone:*
(999)999-9999
Daytime (Work) Telephone No:*
(999)999-9999
Email Address:*
example@example.com
Parent/Guardian #2 Name:

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone:
(999)999-9999
Cell Phone:
(999)999-9999
Daytime (Work) Telephone No:
(999)999-9999
Email Address:
example@example.com
Is a language other than English spoken in the home? If yes, please specify:*

Part II (a) – Family Information, Education
What is your potential college major/career interest? (You can write more than one below:)*

Please check off the highest level of education completed by the parent(s) or guardian(s), whom the student resides with: *

	Elementary	GED/High School	2 Year College	4 Year College
Parent 1
Parent 2
Guardian(s)

Please indicate if your student will be the first generation to complete a Bachelor’s Degree. Potential first-generation college student means:

1. An individual who neither parent(s)/guardian(s) received a Bachelor’s Degree ;

OR

2. A student who, prior to the age of 18, regularly resided with and received support from only one parent/guardian who did not receive a Bachelor’s Degree
First Generation:*

YesNo

FINANCIAL ELIGIBILITY
Student Name:*

First NameMiddle InitialLast Name
SSN:*
999-99-9999
Use filed federal income taxes to complete this form. For independent students, utilize your own tax form. For dependent students, utilize your parent or guardian’s tax form.
1. Federal Income Taxes Used:*

20232022
2. Taxable Income: Line 15 of Form 1040 or 1040-SR*
Non-Tax Filers:

Check box if you did not or will not file tax returns
3. Household Size:*
I certify that the information provided is accurate to the best of my knowledge.

Independent: (only student signature required)

Dependent: (requires BOTH parent/guardian and student too)
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy

Part IV – Academic Records Release Statement
Parent Consent

I do hereby consent to the release of school records (including Transcripts, State Standardized Test Scores, Financial Aid information, ACT/SAT scores, evaluations, recommendations, Date of Birth and Social Security Number for tracking purposes after graduation, and other information regarding my school performance) for my student to Purdue University Northwest Upward Bound program and their designees.
Parent/Guardian #1 Name (Printed):*

First NameLast Name
Parent/Guardian #2 Name (Printed):

First NameLast Name
Parent/Guardian #1’s Signature *

Clear
Date*

MonthDayYear
mm-dd-yyyy
Parent/Guardian #2’s Signature

Clear
Date

MonthDayYear
mm-dd-yyyy

Part IV – Academic Records Release Statement
Student Consent

I do hereby consent to the release of my school records (including Transcripts, State Standardized Test Scores, Financial Aid information, ACT/SAT scores, evaluations, recommendations, Date of Birth and Social Security Number for tracking purposes after graduation, and other information regarding my school performance) to Purdue University Northwest Upward Bound program and their designees.
Student Name (Printed):*

First NameLast Name
Student’s Signature *

Clear
Date*

MonthDayYear
mm-dd-yyyy

TRIO UPWARD BOUND PROGRAM APPLICATION