Bluegrass Community & Technical-Lexington-UB-Application Form

Upward Bound

Application 2024-2025
Bluegrass Com & Tech College
Upward Bound Program
470 Cooper Drive, Oswald Building Room #118, Lexington, KY 40506
Phone: 859-246-6579
Visit us online at: https://bluegrass.kctcs.edu/community/upward-bound

Upward Bound is a Federal TRiO Program funded by the U.S. Department of Education and sponsored by Bluegrass Community a& Technical College, an equal opportunity institution.

Part I—Student Information
Student's Full Name*

First NameLast Name
Preferred Name:*
School:*
Current Grade Level:*
Coursework: (check all that apply to you):*

Dual CreditAP CoursesHonorsAcceleratedTutoring Program
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Social Security Number: (will be held confidential and required for release of education information)*
999-99-9999
Student Cell:*
(999)999-9999
Contact E-mail:*
example@example.com
Date of Birth*

MonthDayYear
mm-dd-yyyy
Gender:*

MaleFemale
GPA:*
Anticipated High School Graduation Year:*
Recommended by:
Attach student’s MOST recent grades/transcript:

Cancelof
Student is a U.S. Citizen:*

YesNo
RACIAL / ETHNIC BACKGROUND (Ethnic/Racial information is for statistical data only & will not be a factor in program eligibility):*

American Indian/Alaskan NativeAsian/Asian AmericanAfrican American/BlackNative Hawaiian/Pacific IslanderHispanic/Latino Caucasian/WhiteOther
I understand that I can only participate in 1 TRiO Program at once (Upward Bound/Educational Talent Search)*

I am not currently a participant in any TRiO ProgramI am a participant in GEAR UP

Siblings*

	Name of School Age Siblings in the Home	Age	Grade	Current School
1
2
3
4

Part II—Parent / Guardian Information

Parent/Guardian Information*

	Parent/Guardian FIRST Name	Parent/Guardian LAST Name	Relationship to Student	Graduated from a 4-year college?	If YES, indicate name of college and year of graduation
1
2

Parent Email:*
example@example.com
Parent Cell Phone:*
(999)999-9999
The Parent/Guardian rights are with:*

Both ParentsSingle ParentParent & Step-parent/partner
Court Appointed Foster parent (attach copy of foster-care documents)

Cancelof
Court Appointed legal Guardian (attach copy of guardianship documents)

Cancelof
Family Guardian, no court or legal document, but I have Educational/Medical Rights for said student

Cancelof
How many people live in household?*
Does student participate in Free Lunch Program?*

YesNo
Tax Status*

YES, the family filed a Federal Income Tax Report for last year.NO, the family DID NOT file a federal income tax report for last tax year.
Check all sources of income:*

Social Services/K-TapAlimonyUnemploymentVeteran BenefitsSNAP BenefitsChild SupportRetirementDisabilitySocial Security/SSI/Survivor’s BenefitsOther
Proof of income will be required during the acceptance process of the application.
Indicate your TAXABLE INCOME amount from tax form: 1040EZ-line 6, 1040-A-line 27, 1040– line 3*

$22,590 under$22,589 to $30,660$30,661 to $38,730$38,731 to $46,800$46,801 to $54,870$54,871 to $62,940$62,941 to $71,010$71,011 to $79,080$79,081 and higher
PLANS AFTER HIGH SCHOOL*

College/UniversityCommunity CollegeWorkMilitaryTrade/Technical/Vocational SchoolOther
Careers/College
What careers interest you?*
What colleges or universities interest you?*

Part IV—Authorizations & Signatures
Authorization to Obtain and Utilize Images ~It is the policy of Bluegrass Community and Technical College Upward Bound that informed writen consent be granted for all photography and or videotaping. By signing below, the parent/guardian of the student applicant hereby grants permission to Upward Bound to photograph and/or vidcotape either the adult parent guardian or the minor child upon admission into Upward Bound. The parent guardian also authorizes Bluegrass Community and Technical College Upward Bound to use and/or permit others to use the afore- mentioned images in educational, informational and promotional activitics for Upward Bound without compensation.

Authorization to Release Academic/Educational Information ~ The parent/guardian authorizes the student's schools to relcase any academic/educational information from the student's files that are requested by Bluegrass Community and Technical College Educational Upward Bound, and authorizes Upward Bound to release academic/educational information to assist in the student's education.
Parent/Guardian Commitment

I give permission for {main_name} to participate in Upward Bound activities during the 2024-2025 academic year beginning September 1, 2024 thru May 31, 2025. I understand the purpose of Upward Bound is to prepare my child to successfully complete a postsecondary education.

I agree to be involved in the following ways:

Allow my child to participate in the required Saturday Academies and summer residential program.

Keep informed of my child’s progress in school.
Allow and encourage my child to attend all Upward Bound activities, meetings, trips (college and cultural) and the summer residential component.

Participate in parent Upward Bound events when scheduled.

Share concerns about my child’s education with Upward Bound staff.

Support the Upward Bound staff in their efforts on behalf of my child.

I agree to the above statements, and certify that, to the best of my knowledge, all information provided herein is correct.
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Student Name*

First NameLast Name
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy

Student Essay
Student Essay a 1 page essay titled “Why I Am Interested in the Upward Bound Program, and How I Might Benefit If Selected”.
Student’s Name

First NameLast Name
Date

MonthDayYear
mm-dd-yyyy

Upward Bound