Jackson State University-Survivors-UB-Application Form

Survivors Upward Bound Program

Student Application
Dear Applicant:

Thank you for your interest in the Jackson State University Survivors 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 instructional 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 Forest Hill High School and the target area. 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 Survivors Upward Bound Program. Please call a staff member at (601) 979- 3139 if you have any questions or need assistance.

Sincerely

LaWanda Smith, Director
Who is Eligible to Participate in the Program?

❖ Are currently enrolled at Forest Hill High School
❖ At least 13 years of age but not older than 19 and completed the 8th grade
❖ 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
College Campus Tours
Cultural Enrichment Activities
Six-Week Summer Camp Program

Jackson State University Survivors Upward Bound Staff:

LaWanda Smith, Director
Office: 601-979-3139
Email: lawanda.y.smith@jsums.edu

Erica Tobias, Administrative Manager
Office: 601-979-0225
Email: erica.d.tobias@jsums.edu

Monica Dickerson, Campus Coordinator (Forest Hill)
Alexis Taylor, Campus Coordinator (Forest Hill)
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 NameLast 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 Birthdate*

MonthDayYear
mm-dd-yyyy
Student Age*
Student Social Security Number*
999-99-9999
FemaleMale
YesNo
American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Pacific IslanderWhiteTwo or More Races
HomelessFoster CareInvolved in the Juvenile SystemNot enrolled in schoolI am not a disconnected youth/at risk student
Name of school currently attending:*
Current Grade:*
Name of school attending next academic year:
Grade Point Average:
Student I.D.
Expected Graduation Date:
4-Year University/College Program2-year College ProgramMilitaryBecome EmployedTechnical/Vocational/Trade ProgramNot Sure
Upward BoundUpward Bound Math/ScienceTalent SearchEducational Opportunity CentersNone
YesNo
If yes,
YesNo
YesNo
If yes, what is your Alien Registration Number (USCIS number)?
Parent/Guardian Information:
Parent/Guardian Name: *

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

Highest Level of Education Completed by:
Mother Name:*

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

First NameLast Name
K-12DiplomaGEDCertificateAssociate’s Degree (2-year)Bachelor’s Degree (4-year)
Guardian’s 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 are in your household?*
Parent/Guardian Occupation:*
YesNo
SNAP/TANFMedicaid/MedicareDisability/Social SecurityOther
Family taxable Income Verification: Please check the income range which reflects the taxable income reported on your family’s 2024 Income Tax Return. Please check an income range even if you were not required to file. If you have not filed taxes yet. Please estimate your taxable income.

Taxable Income Location 1040—Line 10
$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
TutoringGetting 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 Survivors 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 Survivors 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 Survivors 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 Survivors Upward Bound Program. I (We) also authorize the use of my (our) image and name in JSU Survivors 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 Survivors 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 student with a minimum of five (5) sentences.
Please explain why you want to participate in the Jackson State University Survivors Upward Bound Program?
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?

Survivors Upward Bound Program