Lyon College-APPLE Project-UB-Application Form

The APPLE Project Upward Bound, Lyon College
Student’s Name:*

First NameMiddle NameLast Name
Preferred First Name *
Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Cell:*
(999)999-9999
Student Email *
example@example.com
Date of Birth*

MonthDayYear
Date
Gender*

femalemalenonbinary or another gender
Ethnicity*

HispanicAmerican Indian/Alaskan NativeAsianBlack or African AmericanWhiteNative Hawaiian or Islander
Preferred Pronouns:*

he/himshe/herthey/them
Social Security No*
999-99-9999
Current School:*

Batesville High SchoolCave City High SchoolCedar Ridge High SchoolMelbourne High SchoolMountain View High SchoolMidland High SchoolNewport High SchoolSouthside High SchoolTuckerman High School
Current Grade:*

89101112
Age:*
Is the student a U.S Citizen?*

YesNo
Is the student currently:*

in Foster Carein the Juvenile Court SystemHomelessNone of the above
Has the student ever been in another Federally-Funded College Access Program? (i.e. Upward Bound Math Science, Educational Talent Search, GEAR UP, etc.)*

YesNo
Specify:*
Biological/Adoptive Parent or Legal Guardian Information (1)
Parent/Guardian Name:*

First NameLast Name
Relationship to Applicant:*
Cell Phone: *
(999)999-9999
Email: *
example@example.com
Highest Level of Education Completed: *
Student Currently lives with this person:*

YesNo
Biological/Adoptive Parent or Legal Guardian Information (2)
Parent/Guardian Name:*

First NameLast Name
Relationship to Applicant:*
Cell Phone: *
(999)999-9999
Email: *
example@example.com
Highest Level of Education Completed: *
Student Currently lives with this person:*

YesNo
Financial Information
APPLE UB is a federally funded program that requires verification of family income for applicants. All information will remain confidential.
1. Total Number of Individuals Living in Student’s Household (i.e. applicant, parents, siblings, etc.):*
Combined TAXABLE income for the entire household for the most recent tax year (line 15 on 1040 tax form).*
3. Indicate any of the following that the student or members of the student’s immediate family receive (check all that apply):*

Free school lunchesSNAPSocial SecurityMedicaidDisabilityNone of the above
Sign and date below to confirm the financial information recorded in this section is accurate and complete.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Student Self-Evaluation
Post-Secondary Education Goals (Check ALL that apply.)*

Attend College (4 year)Attend Community College (2 year)Vocational or Trade SchoolJoin Military out of High SchoolROTC Military Program in CollegeOther
What is your greatest ACADEMIC strength?*
What is your greatest ACADEMIC need?*
What is something NON-ACADEMIC about yourself that you’d like to work on? *
What is your ultimate career goal or dream job? *
Hobbies, Clubs/Organizations, Sports, etc.*
As of right now, how confident are you that you’ll successfully complete HIGH SCHOOL?*
(1 = Impossible to 7 = Guaranteed)
As of right now, how confident are you that you’ll successfully complete COLLEGE?*
(1 = Impossible to 7 = Guaranteed)
Why do you want to be a part of APPLE UB?*
School Reference

APPLE UB requires the submission of an official school reference form as well as copies of an applicant's transcript, test scores, shot records, and other pertinent academic information. Please select the guidance counselor assigned to you at your school so we can request these documents. Your interview can not be scheduled until these documents are submitted by your school so please make sure your counselor knows you have applied and that we will be in contact with them.
Email*
Counselor or Teacher Name:*
Student Commitment

The information provided above is accurate to the best of my knowledge. I understand that the goal of The APPLE Project Upward Bound is to help students prepare for college. I pledge that it is my desire to enroll in and complete college upon graduation from high school.
Student Signature*

Clear
Date *

MonthDayYear
Date
Parent/Guardian Commitment

As the parent/legal guardian of the student applicant I verify that the information provided is accurate to best of my knowledge. I understand that the goal of the APPLE Project Upward Bound program is to help prepare my child for college. It is my desire for my child to attend college after completing high school. I also authorize the APPLE Project Upward Bound program to obtain and store records of my child’s official transcript, test scores, and other relevant academic information via TRIAND or their school district.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date

The APPLE Project Upward Bound, Lyon College