Wytheville Community College-UB-Application Form

Wytheville Community College

Upward Bound Program

Application for Admission
Upward Bound
Wytheville Community College
1000 E. Main Street
Wytheville, VA 24382

For questions regarding the application process, please contact the Upward Bound office at 276-223-4748 or upwardbound@wcc.vccs.edu.

Upward Bound is a federal TRIO program and is 100% funded by the U.S. Department of Education. Current grant cycle is June 2022 - May 2027.

PROGRAM OVERVIEW
Dear Applicant/Parent/Guardian:

The Wytheville Community College Upward Bound Program would like to welcome you to the application process. Upward Bound is a year-round, federally funded college prep/college access program. Our goal is to assist local students in their pursuit of a college degree. Selection into the program is competitive, but upon acceptance, students remain a participant through high school graduation. All participating students must maintain a 3.0 grade point average and are expected to attend scheduled activities throughout the school year and in the summer. Once accepted into the program, all services provided are free of charge.

The applicant must either be a first-generation college student (parents cannot have earned a Bachelor’s degree or higher), or the applicant must meet income guidelines (defined annually by the federal government).

The WCC Upward Bound program offers a variety of services to high school students during the academic year, including tutoring, academic enrichment activities, college tours, cultural enrichment experiences, academic and career counseling, educational field trips, and personalized educational planning. A summer program is offered on the WCC campus allowing students to take classes designed to prepare them for their next year of study in high school. While the summer program’s focus is academic, it involves a full range of social, cultural, and recreational activities.

Please make sure all required information is provided and all necessary documentation is attached in order for your application to be reviewed. If you have any questions, please feel free to call the Upward Bound office at 276-223-4748.

Sincerely,

Susan Haga, Director

Upward Bound Program

Wytheville Community College

STUDENT APPLICATION
STUDENT APPLICATION

To be completed & signed by BOTH student & parent/guardian
Student Name:*

First NameMiddle NameLast Name
Email:*
example@example.com
Date of Birth:*

MonthDayYear
mm-dd-yyyy
Social Security Number:
999-99-9999
Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Cell #:
(999)999-9999
School Currently Attending:*
Current Grade Level:*
Current Age:*
Gender:

MaleFemale
Citizenship Status: Are you a citizen or permanent resident of the U.S.?*

YesNo
Ethnicity/Race (select all that apply):*

American Indian/Alaskan NativeAsianBlack or African AmericanHispanic/LatinoNative Hawaiian/Other Pacific IslanderWhite
Check all that apply:

Parents divorcedSingle parent homeLive with a guardianIn foster careFather deceasedMother deceased
Name of Parent/Guardian 1:*

First NameLast Name
Check if applicable:

Lives in student’s primary household
Relationship:*
Phone #:*
(999)999-9999
E-mail Address:*
example@example.com
Occupation:*
Educational Status (check one):*

Did not graduate high schoolHigh school graduateSome college2-year college degree (Associate’s)4-year college degree (Bachelor’s) or higher
Name of Parent/Guardian 2:

First NameLast Name
Check if applicable:

Lives in student’s primary household
Relationship:
Phone #:
(999)999-9999
E-mail Address:
example@example.com
Occupation:
Educational Status (check one):

Did not graduate high schoolHigh school graduateSome college2-year college degree (Associate’s)4-year college degree (Bachelor’s) or higher

Complete if applicant has siblings (including step-siblings):

	First & Last Name	Age	School or College/Grade Level
1
2
3
4
5

Please provide a brief paragraph about yourself to include your educational plans beyond high school and reasons for wanting to enroll in the Upward Bound Program. *
In signing this application, I certify that the information given is correct and complete to the best of my knowledge. It is to be used to determine, in part, my eligibility to participate in the Upward Bound Program at Wytheville Community College.
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Parent/Guardian Name*

First NameLast Name
Parent Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Relationship to Student:*
Upward Bound at Wytheville Community College supports the principles of equal educational opportunities without regard to gender, race, national origin, sexual orientation, gender identity, or disability. The following person has been designated to handle inquiries regarding the non-discrimination policies: Malinda Eversole, Director of Human Resources, 105 Carroll Hall, 1000 East Main Street, Wytheville VA 24382, 276-223-4869

HOUSEHOLD INCOME
PARENT INCOME

To be completed & signed by parent/guardian
Name of Student:*

First NameLast Name
Parent/Legal Guardian:

To satisfy a requirement for enrollment in the Upward Bound Program, the TAXABLE family income (line 15 on Tax Form 1040 for year 2022 and 2023) may not exceed certain federal guidelines. In order to proceed with your child’s application, please answer the following financial questions to determine eligibility. This information will be kept confidential and only requested once.
Did you file a Federal Income Tax Return for the most recent year?*

YES, I did file an income tax return for the most recent year.NO, I did not file and won’t file an income tax return for the most recent year.
Attach a signed copy of your 1040 (pages 1 and 2 only) for the most recent tax year - either 2022 or 2023. If desired, you may mark out social security numbers on your tax return for security reasons.*

Cancelof
Please check source(s) of household income.*

Social SecurityChild SupportUnemploymentOther
I have attached a copy of my most recent Federal Income Tax Return (the two-page, signed 1040 Form) or marked the source(s) of household income above. I certify the financial information I have provided is true and accurate to the best of my knowledge.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Relationship to Student:*

CONSENT FOR RELEASE OF INFORMATION
PARENT/GUARDIAN CONSENT FOR RELEASE OF STUDENT DATA/RECORDS

To be completed & signed by parent/guardian
Name of Student:*

First NameMiddle NameLast Name
Student’s Date of Birth:*

MonthDayYear
mm-dd-yyyy
Current Grade Level:*
Parent/Guardian Statement:

I am familiar with the Upward Bound Program at Wytheville Community College and support my son/daughter’s decision to apply for admission to the program.

I give permission for my son/daughter’s middle and high school to release copies of their grades, transcripts, standardized test scores, and other academic records to the Upward Bound Program at Wytheville Community College from the date this form is signed until Upward Bound at WCC receives my son/daughter’s final high school transcript.

I also grant permission for Upward Bound staff at WCC to speak with teachers, counselors, and other school administrators to obtain and exchange information regarding my son/daughter as part of the services provided by Upward Bound.
Name of Parent/Guardian:*

First NameLast Name
Parent/Guardian Signature:*

Clear
Relationship to Student:*
Date*

MonthDayYear
mm-dd-yyyy

STUDENT COMMITMENT
STUDENT COMMITMENT

To be completed & signed by BOTH student & parent/guardian

There are commitments and expectations as an Upward Bound participant. Read the statements below and IF YOU AGREE TO THESE STATEMENTS, please sign. A parent signature is also required.

I {main_name} COMMIT MYSELF:
- to remain in Upward Bound until high school graduation.
- to maintain a 3.0 or higher cumulative grade point average during high school.
- to work toward an Advanced High School Diploma.
- to attend the Summer Enrichment Program the summer immediately following my enrollment in Upward Bound.
- to regularly attend during the academic year which includes Upward Bound staff monthly school visits, academic & cultural enrichment activities / field trips, and virtual events.
- to use Upward Bound provided tutoring services and to inform Upward Bound staff if further tutoring is needed.
- to demonstrate acceptable behavior while participating in all Upward Bound activities (consistent with expectations in local schools).
- to enroll in post-secondary education after high school graduation and complete an Associate or Bachelor’s Degree.
I understand to not honor these commitments could ultimately result in being dismissed from the Upward Bound Program.
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Parent/Guardian Name:*

First NameLast Name
Relationship to Student:*
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy

PARENT COMMITMENT
PARENT COMMITMENT

To be completed & signed by parent/guardian
Student's First and Last Name:*

First NameLast Name
Parent's First and Last Name:*

First NameLast Name
The following statements need parent approval:

· I give permission for my child to participate in the Summer Enrichment Program, field trips, college tours, virtual events, and academic/cultural enrichment experiences provided by the WCC Upward Bound Program.

· I give permission for my child to be transported by county school bus, college vehicles and/or commercial chartered buses for scheduled activities, field trips, college visits, cultural enrichment experiences, or other general program needs. I will be responsible for transporting my child to and from assigned “pick-up” locations.

· I understand that the Upward Bound staff is required to track my child’s progress from high school through college graduation.

· I assume responsibility for any damage to property, to include the college, high school or other facilities, brought about by my child while engaged in Upward Bound activities.

· My child and I give permission to use his or her picture(s) in recruiting materials such as brochures, PowerPoint slide shows, etc., and for social media pages developed by Upward Bound.

· I understand that my child is required to regularly attend Upward Bound activities during the summer and academic year.

· I understand that my child must maintain at least a 3.0 cumulative grade point average throughout high school.

· I understand that my child will risk possible release from Upward Bound for failing to comply with program expectations.

My signature below indicates that I have reviewed and agree to the above statements and give permission for my child to participate in Upward Bound at WCC.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Relationship to Student:*

MEDICAL INFO. & CONSENT
MEDICAL INFO. & CONSENT

To be completed & signed by parent/guardian

Parent/Guardian, please provide the following information regarding your child:
Name of Student: *

First NameLast Name
Person to contact if unable to reach parents:*
Relationship to student:*
Phone #*
(999)999-9999
Student’s physician*
Doctor’s office phone #*
(999)999-9999
Please List:
Health issues Upward Bound staff should be aware of such as diabetes, epilepsy, asthma, ADHD, depression/anxiety, etc.*
Medications presently taking:*
Food allergies:*
Medication allergies:*
Other allergies:*
Other health-related information you would like to share:*
I give permission for Upward Bound staff at Wytheville Community College to arrange any needed medical services in emergency situations for my child listed above.
Parent/Guardian Name:*

First NameLast Name
Relationship to Student:*
Parent/Guardian Signature:*

Clear
Date:*

MonthDayYear
mm-dd-yyyy