Jackson State University-Conquerors-UB-Application Form

Conquerors Upward Bound Program Student Application
1400 J.R. Lynch St. / PO Box 17083 / Jackson, MS 39217 / Phone: (601) 979-0682 / Email: conquerorsupwardbound@jsums.edu

This is for the student and parent/guardian to keep for your records. Please do not return with application.

Dear Applicant:

Thank you for your interest in the Jackson State University Conquerors Upward Bound Program. Upward Bound is a free college preparatory program for high school students funded by the U.S. Department of Education and sponsored locally by Jackson State University. Upward Bound is designed to provide participants the skills and motivation necessary to navigate and complete a program of secondary education and to enter and succeed in a program of post-secondary education.

Upward Bound is a year-round program. The program provides tutorial services, classes, and special events during the school year to strengthen academic skills and prepare students for success at the college level. The program also provides academic advising and individual assistance with the college admissions and financial aid application process during the academic school year. Our six-week summer academic component is designed to simulate a college-going experience that includes daily coursework in math, laboratory science, composition, literature, foreign language as well as cultural, social, and recreational events and activities.

Eligibility to participate in the program is determined individually. Each applicant must meet basic eligibility requirements set forth by the U.S. Department of Education, that require neither parent to have a four-year college degree and family income verification. Our program services 60 students from Jim Hill, Lanier, and Provine High Schools. Therefore, it is important that you complete your application as soon as possible. When space is not available, an application will be placed on our waitlist for later consideration.

All completed applications will be reviewed and eligible applicants contacted for a student and parent interview with program staff.

Thank you for your interest in the JSU Conquerors Upward Bound Program. Please feel free to call a staff member at (601) 979-0682 if you have any questions or need assistance.

India Johnson

Director

Conquerors Upward Bound Program

Who is Eligible to Participate in the Program?

Are currently enrolled at Jim Hill, Lanier, and Provine High Schools

At least 13 years of age but not older than 19

U.S. citizen or permanent resident

First-Generation (a student whose parent did not complete a 4-year college or university degree)

Meet the low-income requirements as defined by the Federal Government

An individual who has a high risk for academic failure

Free Services Offered by the Upward Bound Program

Preparation of Educational Plans

Academic Advisement

Career Exploration

Information on Post-Secondary Education

Financial Aid (FAFSA) Assistance

American College Test (ACT) Prep

Tutoring (FREE)

College Campus Tours

Cultural Enrichment Activities

Six-Week Summer Camp Program

Jackson State University Conquerors Upward Bound Staff:

Office: 601-979-0682

Instructions for completing this form:

1. Read each question carefully and complete all sections by writing in black or blue ink or typing on the computer.

2. If you fail to answer all necessary questions and/or omit signatures, your application will be returned to you for completion.

3. Students cannot participate in program activities until all application materials are complete and returned to the address above.

4. If you are under the age of 19, you and your parent or guardian must sign all application materials.

***The information you provide on this application will be secure and confidential***
Student Name:*

First NameMiddle InitialLast Name
Contact Information:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Email:*
example@example.com
Parent/Guardian Email:
example@example.com
Home Phone
(999)999-9999
Student Cell Phone
(999)999-9999
Parent/Guardian Cell Phone
(999)999-9999
Parent/Guardian Work Phone
(999)999-9999
Student Information:
Birthdate

MonthDayYear
mm-dd-yyyy
Age
Social Security Number*
999-99-9999
*Required by the US Department of Education
FemaleMale
YesNo
American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Pacific IslanderWhiteTwo or More Races
Name of school currently attending:
Current Grade:
Name of school attending next academic year:
Student ID:
Grade Point Average:
Expected Graduation Date:

MonthDayYear
mm-dd-yyyy
4-Year University/College Program2-year College ProgramMilitaryBecome EmployedTechnical/Vocational/Trade ProgramNot Sure
Upward BoundUpward Bound Math/ScienceTalent SearchEducational Opportunity CentersNone
YesNo
If yes, explain:
YesNo
YesNo
If yes, what is your Alien Registration Number (USCIS number)?
YesNo
Parent/Guardian Information:
Parent/Guardian Name:

First NameLast Name
Relationship to Student:
SingleMarriedDivorcedWidowSeparated
First Generation Eligibility Verification (Completed by Parent/Guardian)
Mother’s/Guardian Name:

First NameLast Name
K-12DiplomaGEDCertificateAssociate’s Degree (2-year)Bachelor’s Degree (4-year)
Father’s/Guardian Name:

First NameLast Name
K-12DiplomaGEDCertificateAssociate’s Degree (2-year)Bachelor’s Degree (4-year)
FIRST-GENERATION CERTICATION STATEMENT - Completing this form, which will serve as a statement of Educational attainment, you are certifying that the information submitted regarding parent/guardian Educational attainment is true to the best of your knowledge.
Parent/Guardian Signature:

Clear
Date

MonthDayYear
mm-dd-yyyy
Income Verification Information

As a federally funded free program for students, Upward Bound is required to verify income levels.
How many people live in your household?
Parent/Guardian Occupation:
SNAP/TANFMedicaid/MedicareDisability/Social SecurityOther
$0 – $23,940$23,941 – $32,460$32,461 – $40,980$40,981 – $49,500$49,501 – $58,020$58,021 – $66,540$66,541 – $75,060$75,061 – $83,580$83,581 or greater
INCOME CERTIFICATION STATEMENT - By completing this form, which will serve as a statement of income, you are certifying that the information submitted regarding the family size and taxable income is true to the best of your knowledge.
Parent/Guardian Signature:

Clear
Date:

MonthDayYear
mm-dd-yyyy
Academic Need Assessment
Tutoring Getting better gradesLearning how to take better notesACT/SAT/Subject Area Test PrepChoosing classes that will prepare me for collegeApplying for financial aid/scholarships/grantsImproving self-esteem and social skillsChoosing a career/college major that’s best for meKnowing how to prepare for a career that interests meTest-taking strategies and techniquesDeveloping or improving my time management skills/habitsImproving study skills and habitsApplying for college admissionsOpportunities to visit collegesExperience more cultural activitiesReceive information on college prep courses and dual enrollmentReceive information about college programs and degrees
YesNoN/A
YesNoN/A
YesNoN/A
YesNoN/A
YesNoN/A
If yes, please explain
School Record Release, Waiver to Provide Services, and Post-High School Tracking Release
By signing here, I understand that as a part of the Jackson State University Conquerors Upward Bound Program selection process, my child’s school records including transcripts, progress reports, standardized test scores, attendance records, disciplinary actions, evaluations, and medical records will be examined. I also understand that if my child is selected for the Jackson State University Conquerors Upward Bound Program, the Upward Bound Program will continue to require this information from my child’s high school and college. This information is necessary to track the performance of the Program’s participants and graduates. I hereby give permission for Jackson State University Conquerors Upward Bound Program to request the above information from my child’s high school and future colleges that he/she may attend.
Student Name:

First NameLast Name
Parent/Guardian Signature:

Clear
Date:

MonthDayYear
mm-dd-yyyy
Certification of Application and Information Release
I (We) certify that the information provided on the application is true and correct to the best of my (our) knowledge; I (We) further understand that the completion of this application does not guarantee acceptance into the JSU Conquerors Upward Bound Program. I (We) also authorize the use of my (our) image and name in JSU Conquerors Upward Bound publications, editorials, advertisements, and media releases to the program and its affiliates organizations. My (Our) consent will remain in effect until I (We) revoke this authorization, in writing, with the JSU Conquerors Upward Bound office.
Student Name:

First NameLast Name
Student Signature:

Clear
Date:

MonthDayYear
mm-dd-yyyy
Parent/Guardian Name:

First NameLast Name
Parent/Guardian Signature:

Clear
Date:

MonthDayYear
mm-dd-yyyy
Applicant Essays

Both essays must be completed by the applicant with a minimum of five (5) sentences.
Please explain why you want to participate in the Jackson State University Conquerors Upward Bound Program?
YesNoN/A
Upward Bound is committed to helping students get into college and complete a degree to become successful in a career of their choice. What is your intended major or career? Why?

Conquerors Upward Bound Program Student Application

Contact Information:

Student Information:

Parent/Guardian Information:

First Generation Eligibility Verification (Completed by Parent/Guardian)

Income Verification Information

Academic Need Assessment

School Record Release, Waiver to Provide Services, and Post-High School Tracking Release

Certification of Application and Information Release

Applicant Essays