University Of South Carolina-Lancaster-UB-Application Form

Please complete this application if you are interested in becoming a member of USC Lancaster TRiO Upward Bound.

The application will not be complete until we receive your income verification, a copy of page one of your most recent IRS 1040 tax return.

1. Full Name:*

First NameLast Name

2. Home address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

3. Mailing address if different from home address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

4. Student cell phone number:*

(999)999-9999

5. Home phone number:

(999)999-9999

6. Date of birth:*

mm-dd-yyyy

7. Gender*

MaleFemale

8. Ethnicity (Check all that apply)*

9. Which high school will you attend in the Fall?*

Andrew Jackson High SchoolBuford High SchoolLancaster High School

10. What year will you graduate high school, (for example, graduates completing high school in 2025 will enter 2025; graduates completing high school in 2028 would enter 2028)? Please enter the year you are expected to graduate high school:*

11. Did either of your parents complete 4 years of college?*

YesNo

12. If yes to the previous question, please identify which parent.*

13. What is the total number of people in household (include yourself)?*

14. Which range below best describes your family Taxable Income from your most recently completed tax form (1040 (line 43) or 1040A (line 27) or 1040EZ (line 6)?*

Income ranges between $00,000 – 22,590Income ranges between $22,591 – 30,660Income ranges between $30,661 – 38,730Income ranges between $38,731 – 46,800Income ranges between $46,801 – 54,870Income ranges between $54,871 – 62,940Income ranges between $62,941 – 71,010Income ranges between $71,011 – 79,080

15. Does your family qualify for Free or Reduced Lunch?*

YesNo

16. Student School e-mail:*

example@example.com

17. Student Personal e-mail:*

example@example.com

18. Name of parent or legal guardian: *

First NameLast Name

19. Parent or legal guardian cell phone number:*

(999)999-9999

20. Parent or legal guardian e-mail address:*

example@example.com

21. What is your most recent GPA; or grades from your most recent report card or progress report?

22. What are your plans after completing high school?

23. Do you have any documented learning, physical or emotional disabilities?*

YesNo

24. If yes to the previous question, please clarify which disability and briefly explain.

25. TRiO Upward Bound Terms and Conditions:

Personal Conduct & Responsibility: All TRiO staff, students and guests are expected to be respectful and courteous at all times. Students are expected to deal with conflict nonviolently. When experiencing a conflict, we expect you to talk to that person and notify the Upward Bound staff. Ask for help if you feel uneasy on your own.

Gambling, public nudity, theft, vandalism, drug use, smoking or vaping, sexual activity, foul language and violent behavior will not be tolerated. Inappropriate use of university buildings, including computer labs, may result in your dismissal from the program.

Attendance & Participation: You are expected to be on time and to fully participate in all scheduled activities. Participants must notify the staff of absences in advance regarding conflicting school activities or family responsibilities. In case of illness, injury or emergencies please contact the Upward Bound staff within 48 hours to inform them of the situation. Excessive unexcused absences may result in your dismissal from the program.

Appropriate Dress: Wear clean clothes that provide appropriate body coverage (no tank tops or mid-drift tops). Shorts may be worn, but not short-shorts. Shirts and shoes are required except when you are allowed in the pool. Hoods from hoodies are not to be worn inside. Any clothing that promotes the use of alcohol, tobacco or other drugs; that is disrespectful or obscene; and makes reference to sexual activity, violence or illegal activities are not allowed. Ask a staff member if you are unsure about what to wear. REMEMBER: Your clothing choices reflect on you as well as Upward Bound! Upward Bound staff will make the final decision about the appropriateness of students’ dress.

Cell Phone & Earbuds Policy: Cell phones or earbuds cannot be used anytime during sessions unless authorized by the staff. TRiO staff phones are available in each staff work area.

Authorization for Media Release: I hereby grant authorization for my child to be featured in Upward Bound media releases (newspapers, radio, television, Internet, social media, etc.). I understand that this includes the use of photographs and/or videos.

Parent and student must type initials in the response acknowledging they have read and agree to these terms and conditions!*

You and your parent's typed name below acknowledges that the information provided in this application is accurate and complete.

It also acknowledges that the student and parent have read, understand, agree to and consent to all expectations outlined in this application.

You and your parent's signature also authorizes the Lancaster County School District to release academic records as needed to support the USCL TRiO Upward Bound Program.

26. Student's typed name verifying agreement:*

First NameLast Name

27. Parent's typed name verifying agreement:*

First NameLast Name

Upward Bound Application