Pennsylvania Western University-Californa-Fay-UB-Application Form

TRIO Upward Bound

Pennsylvania Western University (California)
Student Application Form

Student:

Complete all sections of this form along with a parent or guardian.

A Student Recommendation form will be sent to you and your school counselor to be completed.

Ask your parent/guardian to complete the Income Verification section of the application.

Transcripts, Report Cards and PSAA results will be requested from the school counselor.

Questions? Contact Upward Bound at 724-938-4470 or upwardboundcal@pennwest.edu

Legal Name (First/Last include Middle Initial if applicable)

First NameMiddle InitialLast Name
Chosen/Preferred First Name
Pronouns
Gender:
Social Security Number
999-99-9999
Landline Phone Number
(999)999-9999
Student Cell Number
(999)999-9999
Parent/Guardian 1 Name

First NameLast Name
Parent/Guardian 1 Relationship to Student
Parent/Guardian 1 Cell Number
(999)999-9999
Parent/Guardian 1 E-mail Address
example@example.com
Parent/Guardian 2 Name

First NameLast Name
Parent/Guardian 2 Relationship to Student
Parent/Guardian 2 Cell Number
(999)999-9999
Parent/Guardian 2 E-mail Address
example@example.com
Mailing Address (Include PO or Apt numbers)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current Grade
School
Date of Birth

MonthDayYear
mm-dd-yyyy
Student E-mail Address
example@example.com
Ethnic/Racial Background (Check all that apply)
Are you a U.S. citizen?
Are you in foster care?
All questions in the section below must be answered and completed by the STUDENT ONLY!
List any clubs, activities, or organizations that you participate in, both in and out of school:
Why do you think you should be considered for admission into the Upward Bound program at PennWest California?

Did you file a tax return this year?
1: Please complete this box ONLY if you filed a tax return this year. Otherwise, please skip to the next box.
Total TAXABLE income from your tax form for the student’s primary residence for last year.
How many people currently reside within your household according to your taxes?
Is the family income for this year significantly more or less than last year?
If yes, why?
1a: If you did not file a tax return this year, please complete this option. Otherwise, please skip.
What was your actual household income (from all sources) last year?
What is your estimated household income for this year?
How many people currently reside within your household according to your taxes?
Does the student and/or student’s family receive any of the following types of nontaxable income? (Please put a check after each item only if the answer is yes.):

Other

Have any of the people listed below ever received a four-year college degree (a bachelor’s degree)? (Please check all that apply.):

Rows	Yes	No
Biological/Adoptive Parent 1:
Biological/Adoptive Parent 2:
Guardian (if applicable):

Please list all members of your household (people who live in the house including the student) below:

Rows	Name	Age	Relation To Student	Occupation/Employer	Highest Education Completed
1
2
3
4
5
6
7
8
9

By signing below, I certify that all of the information on this form is true and complete to the best of my (our) knowledge. If requested by the TRIO Upward Bound program, I (we) agree to give proof of the information that I (we) have given on this form, including a copy of my (our) federal or state income tax return.
Parent / Guardian Name

First NameLast Name
Parent / Guardian Signature
Today's Date

MonthDayYear
mm-dd-yyyy

PLEASE READ CAREFULLY –

ì I understand that the TRIO Upward Bound program at Pennsylvania Western University - California has academic, behavioral, and program requirements. I agree to comply fully with all of them, including the program’s academic and participation requirements, and agree to take full advantage of all the services that TRIO Upward Bound offers.

ì I authorize the TRIO Upward Bound program to have access to all academic records from my current school, as well as any schools that I may have attended in the past. I understand that these materials will be used by the TRIO Upward Bound staff in selecting qualified candidates for the program and for monitoring my academic progress. I also grant continued access to all my academic records, including transcripts, until my graduation and during my future enrollment in a program of postsecondary education. This complies with the Family Educational Rights and Privacy Act of 1974 (Public Law 93 - 80, Section 513(b)(4)(a).

ì If accepted as a participant, I grant TRIO Upward Bound the permission to use my name, picture, and/or written word in any newsletters, web pages, social media sites, videos/DVDs, brochures, or other public relations materials highlighting the TRIO Upward Bound program.

With my signature below, I agree to the items listed above and verify that the information that I have provided throughout this application is true and accurate to the best of my knowledge.
Student's Name

First NameLast Name
Student’s Signature
Today's Date

MonthDayYear
mm-dd-yyyy

PLEASE READ CAREFULLY –

ì As a parent or guardian, I hereby give my permission for the applicant to participate in the TRIO Upward Bound program at Pennsylvania Western University - California and release the program and staff from any liability that may result. I also pledge to encourage and support their full involvement in the program until graduation.

ì I understand that the Family & Income Verification section is also required as part of the applicant’s application for admission to the TRIO Upward Bound program. I understand that responses in this section will be treated as highly confidential by the program staff. Income is used for the sole purposes of federal eligibility selection criteria.

ì I grant TRIO Upward Bound permission to use the applicant’s name, picture or written word in any newsletters, social media sites, web pages, videos/DVDs, brochures, or other public relations materials highlighting the TRIO Upward Bound program.

ì I understand that the applicant may be contacted through various means of communication, including mail, social media, instant message, text, email, etc. for educational and extracurricular purposes.

With my signature below, I agree to the items listed above and verify that the information provided throughout this application is true and accurate to the best of my knowledge
Parent/Guardian Name

First NameLast Name
Parent / Guardian Signature
Today's Date

MonthDayYear
mm-dd-yyyy

The following information deals with confidentiality and the federal Privacy Act.

The information provided to the TRIO Upward Bound program is used to compile data that is sent to the U.S. Department of Education. The federal Privacy Act protects this information. No one may see the information unless they work for or with the TRIO Upward Bound program and are specifically authorized to access it. The information is necessary to determine if the student named below is eligible to participate in the program and to assist in measuring the success of the program. The U.S. Department of Education has the authority under federal law to gather information to help make TRIO Upward Bound a better program (20 USC 1231a).

By signing below, we understand that this form will be retained by TRIO Upward Bound and will be utilized to access yearly academic records, such as high school transcripts, report cards, class schedules, assessment results, and other academic records, and to verify academic progress and the student’s financial aid status once the student enrolls in a program of postsecondary education.

We hereby authorize the release of any information regarding the student named below to the TRIO Upward Bound program at Pennsylvania Western University - California. This authorization shall remain valid until his/her graduation from high school and during all subsequent periods of enrollment in postsecondary education.
Student’s Name

First NameLast Name
Student’s Signature
Today's Date

MonthDayYear
mm-dd-yyyy
Parent/Guardian Name

First NameLast Name
Parent/Guardian Signature
Today's Date

MonthDayYear
mm-dd-yyyy

TRIO Upward Bound