Jackson State University-Navigators-UB-Application Form

Jackson State University-Navigators-UB-Application Form
Dear Applicant:

Thank you for your interest in the Jackson State University Navigators 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. It is designed to provide participants with the skills and motivation necessary to navigate and complete a secondary education program and to enter and succeed in a post-secondary education program.

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 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, and 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 Department of Education, which require neither parent to have a four-year college degree and family income verification. Our program serves 60 students from Callaway and Murrah High Schools. Therefore, you must complete your application as soon as possible. When space is unavailable, an applicant will be placed on the waitlist for later consideration.

All completed applications will be reviewed, and eligible applicants will be contacted for a student and parent interview with program staff. Thank you for your interest in the Navigators Upward Bound program. Please call a staff member at (601) 979-0327 if you have any questions or need assistance.

Sincerely,

Corinthia Bradfield, Director

Demographic Information:
Name*

First NameMiddle NameLast Name
Street Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number*
999-99-9999
Date of Birth *

MonthDayYear
Date
Age*
Gender*
Citizenship*
Alien Registration Number
Please select languages spoken at home *
Ethnicity*
Home phone number *
(999)999-9999
Cell phone number*
(999)999-9999
Student email address *
example@example.com
Disconnected Youth*

Academic Need Assessment:

Please respond to each statement below by selecting yes or no.*

	Yes	No
Tutoring
Assistance with getting better grades
Assistance in learning how to take better notes
Assistance in choosing classes that will prepare me for college
Assistance in applying for financial aid/scholarships/grants
ACT/SAT/Subject Area Test Prep
Are you interested in pursuing a career in the fields of math or science?
Assistance in choosing a career/college major that is best for me
Assistance in knowing how to prepare for a career that interests me
Assistance in test-taking strategies and techniques
Assistance in developing or improving my time management skills/habits
Improving my study skills and habits
Assistance in applying for college admission
Opportunities to visit colleges
Experience more cultural activities
Receive information on college prep courses and dual enrollment
Receive information about college programs and degrees

Applicant Essays:
Please explain why you want to participate in the Jackson State University Navigators Upward Bound Program *
Upward Bound is committed to helping students enroll in college and complete a degree to succeed in their chosen career. What is your intended major or career? Why? *

First Generation Eligibility Verification:
Father/Male Guardian Name*

First NameLast Name
Is he living?*

YesNoUnknown
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Guardian Educational Level *
Place of Employment
Cell Phone Number
(999)999-9999
Home Phone Number
(999)999-9999
Email Address
example@example.com
Mother/Female Guardian Name *

First NameLast Name
Is she living?*

YesNoUnknown
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Guardian Educational Level *
Place of Employment
Cell Phone Number
(999)999-9999
Home Phone Number
(999)999-9999

Income Verification Information:
How many people live in your household? *
Source of Income: Please select the primary source of income*
Household Income Range*

School Records Release
I understand that as part of the Jackson State University Navigators Upward Bound Program selection process, my child’s school records, including transcripts, test scores, and academic progress reports, may need to be examined.

I also understand that if my child is selected for the Jackson State University Navigators Upward Bound Program, the Upward Bound Program will continue to require this information from my 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 Navigators Upward Bound Program to request the following information from my child’s high school and future colleges that he/she may attend:

1. Transcripts

2. Progress reports

3. Standardized test scores

4. Attendance records

5. Disciplinary Actions

6. Evaluations

7. Medical records

The Family Educational Rights and Privacy ACT (FERPA), 20 U.S.C §1232g, are respectively federal and state laws providing for the review and disclosure of student educational records. JSU Navigators Upward Bound Program will not permit access to or the release of personally identifiable information contained in the student educational records to any party without the written consent of the students, except as authorized by FERPA.

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 completing this application does not guarantee acceptance into the JSU Navigators Upward Bound program.

I/WE authorize using my image and name in JSU Navigators Upward Bound publications, editorials, advertisements, and media releases to the program and its affiliated organizations.

My/Our consent will remain in effect until I/We revoke this authorization, in writing, with the JSU Navigators Upward Bound office.
Student Signature *

Clear
Date*

MonthDayYear
Date
Parent/Guardian Signature *

Clear
Date*

MonthDayYear
Date