Pensacola State College-VUB-Application Form

APPLICATION FOR SERVICES
Name*

First NameMILast Name
DOB:

MonthDayYear
mm-dd-yyyy
Date:

MonthDayYear
mm-dd-yyyy
Street Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone 1:

HomeCellWorkOther
Phone 1:
(999)999-9999
Phone 2:

HomeCellWorkOther
Phone 2:
(999)999-9999
E-mail Address:*
example@example.com
Gender:

MaleFemale
Marital Status:

SingleMarriedSeparatedDivorcedWidowed
Ethnicity:

WhiteAsianBlack/African AmericanHispanic/LatinoNative Hawaiian/PacificIsland AmericanIndian/Alaskan AmericanTwo or more races
Are you a US Citizen?

YesNo
If no, Alien registration #:
VUB may text message me. I understand that I am responsible for any charges from my carrier. Standard text rates may apply.

I AuthorizeI Do Not Authorize
Applicant Signature

Clear
Did either one of your parents or guardians, who raised you,graduate from a 4-year college/university before you were 18?

YesNoN/AUNK
Did you serve at least 181 day of active duty?

YesNo
Are you a Veteran?

YesNo
Branch of Service:

ArmyNavyAir ForceMarine CorpsCoast GuardSpace Force
Date of Discharge:

MonthDayYear
mm-dd-yyyy
Type of Discharge:

HonorableGeneralOther than HonorableBad ConductDishonorableOther
Education benefit plan:

MGIB-AD (chapter 30)Post-911 (chapter 33)MGIB- SR (chapter 1606)REAP (chapter 1607)DEA (chapter 35)VocRehab (chapter 31)
Highest Level of Education

1-56-89-12GEDHigh School DiplomaSome collegeAssociatesBachelorsMastersDoctorate
Credit hours accumulated:
Employment:

UnemployedPart-TimeFull-TimeRetired
Were you discharged with or currently have a service-connected disability?

YesNo
Current rating:
%
Which Veterans Upward Bound services are you interested in?

Assessment of academic skillsDevelopment of an education/ career planGED completionAssistance with Financial AidVeterans’ benefits applicationsCommunity/ veterans’ agencies and supportive services referralsAssessment of career interestsAssistance with post-secondary school applicationsInformation about college degree plans and programsStudy SkillsCollege visits/ toursAcademic refresher coursesMathematicsScienceReading/ Writing ComputerSkillsForeign LanguageOther
After completing the Veterans Upward Bound program, what are your educational plans?

Community CollegeVocational / Technical SchoolGED only (no school after VUB)College/ UniversityEmployment only (no school after VUB)
If you are planning to continue your education what degree and/or course of study/program are you interested in.
I would like to participate in the Veterans Upward Bound program, hosted by Pensacola State College, and receive the free services provided. I hereby certify that the information provided in this application is accurate and complete to the best of my knowledge.
Applicant Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
I agree that if I am accepted in the VUB program, the staff may include my name and/or picture in publications, including their website. These publications highlight student accomplishments and participation in VUB activities.
Applicant Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Confidentiality Statement: All infor mation provided is kept confidential and is shared among the VUB staff and other college officials only on a need-to-know basis. The following limits to confidentiality apply: When child/elder abuse is disclosed, when a threat to self or others is disclosed, or when records are legally subpoenaed.
Applicant Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Affidavit/Release of Information: I certify that the information I have provided on this application is to the best of my knowledge, complete and accurate. I hereby authorize the VUB program and all other appropriate college departments, including Financial Aid, to share academic and Financial Aid records that will help in assessing my academic and career planning needs. I understand, in order to confirm or facilitate transfer and graduation, my information may be shared by or with other postsecondary institutions or organizations, such as the National Student Clearinghouse. I also authorize the VUB program to print my name and photograph, as appropriate in articles in the VUB newsletter, social media, and promotional materials.
Applicant Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Pensacola State College does not discriminate against any person on the basis of race, ethnicity, national origin, color, gender/sex, age, religion, marital status, pregnancy, disability, sexual orientation, gender identity, or genetic information in its educational programs, activities, or employment. For inquiries regarding Title IX and the College’s nondiscrimination policies, contact the Executive Director of Equal Opportunity Compliance at (850) 484-1759, Pensacola State College, 1000 College Blvd., Pensacola, Florida 32504.
We are serious about helping you to reach your goals. In order for VUB to meet your needs effectively, it is important that you understand the role you play in reaching your educational goals. Please read, initial and sign the following terms and
conditions of the Veterans Upward Bound program to demonstrate your understanding.
- I understand the requirements, as stated in the VUB Program information, necessary for stipend eligibility.
- All materials are property of Veterans Upward Bound
- VUB provides financial aid guidance, not assistance. We will help you with your search for financial assistance however; we do not have funds to pay for tuition, books or other school related materials.
- VUB provides academic advice; ultimately, it is your choice whether to listen to our advice.
- I understand that the VUB staff is available to provide support and assistance if an issue, problem or concern arises.
- I will complete all program requirements as outlined in my Individual Education Plan.
- I will not withdraw from the program before I meet with the Director.
- I will respect and have a positive attitude about staff, instructors, tutors, my fellow classmates, the campus community and myself.
- I will participate in VUB activities and encourage others to participate in activities in which they are invited to attend.
- I will arrive on time for VUB events that I have signed-up to attend. If I am unable to attend the event, I will inform a VUB representative immediately.
- I will attend my scheduled classes on time and ensure that my name is on the attendance list. If I am unable to attend a class I will immediately contact a VUB representative to inform them of my absence and the reason for the absence.
- If I arrive late to class or leave class early, I will inform my instructor immediately.
- I will read and adhere to the syllabus for each class.
- I will try my best in each class.
- I will ask questions about the program, class or lesson if any information is unclear.
Applicant Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
STIPEND POLICY
Effective 17 April 2017

Veterans Upward Bound (VUB) participants may qualify for a payment - called a stipend - for each term that they participate in the program. VUB will provide each applicant with a maximum stipend of $40 per month ($30 for class attendance and $10 for event attendance), payable at the end of each eight-week term, dependent upon the applicant meeting the following requirements:
- All records and VUB forms must be complete. DD-214 (or the request for a copy) must be submitted and the VUB application, contract, and all other appropriate VUB forms must be completed and signed by the applicant.
- VUB applicants must…….
  — Take both a pre test and post test (when scheduled) to assess academic progress.
  — Meet with a VUB Academic Advisor at least once a term as scheduled.
  — Attend a VUB sponsored Math, English, Science, Computer, or Foreign Language class
  - No more than two unexcused absences
  - Complete a total of eight hours of ComFit Online learning during the eight week term
    —or— (if not possible to be scheduled for a VUB Class)
    — Use the ComFit Online Learning Center for at least 32 hours during the eight week term
    —or—
    — Receive at least 32 hours of tutoring from VUB Tutors during the eight week term
- Applicant must maintain satisfactory progress and must complete all assignments. Satisfactory progress is determined based on the professional judgment of the Director, with input from Instructors, Academic Coordinator, and tutors.
- An applicant may also be eligible for a partial stipend for attending events if they have successfully completed a class the previous term.
Payment of stipend
- The maximum amount awarded for each month is $40.00 ($30.00 class attendance and $10.00 event attendance) and the maximum for each two-month term is $80.00.
- Stipend checks will be mailed to your address approximately four weeks after the end of the term.
- Textbooks are the property of VUB and must be returned. Your last stipend check will be withheld or forfeited if textbooks are not returned upon withdrawal or completion of the program.
- Cashing your check in a timely manner is your responsibility. Stipend checks will be void 180 days after issue.
This policy is subject to revision at any time.

I have read the VUB stipend policies and agree that it is my responsibility to know the policies and to attend scheduled meetings and classes.
Applicant Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
INCOME VERIFICATION FORM
Name:

First NameLast Name
What is you Family TAXABLE Income for 2023?
How many people are dependent of this income (include yourself)?
Did you file a tax return for the most recent tax year?

YesNo
My signature below reflects that the information listed above is true.
Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
INDIVIDUAL EDUCATION PLAN
Name:

First NameLast Name

Subjects

	Information
ENGLISH
MATH
COMPUTER
SCIENCE
SPANISH
COMFIT/TUTORING
COLLEGE APPLICATION
FAFSA/EOC
WORKSHOP #1
WORKSHOP #2
CULTURAL OUTING
COLLEGE VISIT

VUB Academic Map-Term 1

	Method of Instruction
MAT 0001
MAT 0002
ENG 0001
ENG 0002
COM 0001
COM 0002
SCI 0001
SPN 0001

VUB Academic Map-Term 2

	Method of Instruction
MAT 0001
MAT 0002
ENG 0001
ENG 0002
COM 0001
COM 0002
SCI 0001
SPN 0001

Student Needs

GED AssistanceWriting SkillsChoosing a MajorGoal SettingTaking TestsFinding a CollegeHow to StudyTest AnxietyFinancial Aid HelpManaging TimePublic SpeakingBasic NeedsTaking NotesCritical ThinkingEmploymentReading SkillsCareer GuidanceChild Care/ Elder CareTutoringCounseling
Applicant Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Individual Education Plan Notes:
Name

First NameLast Name
Phone
(999)999-9999
ACADEMIC COUNSELING
DATE:

MonthDayYear
mm-dd-yyyy
COUNSELOR:
STUDENT INITIALS:
NOTES:
ACADEMIC COUNSELING
DATE:

MonthDayYear
mm-dd-yyyy
COUNSELOR:
STUDENT INITIALS:
NOTES:
ACADEMIC COUNSELING
DATE:

MonthDayYear
mm-dd-yyyy
COUNSELOR:
STUDENT INITIALS:
NOTES:
REQUEST for STUDENT TESTING Referral Form
Legal Name:

First NameMiddle NameLast Name
Pensacola State College Student ID:
Date of Birth

MonthDayYear
mm-dd-yyyy
Please indicate the appropriate test requested with a checkmark.
PERT: Parts of PERT Test Needed:

All PartsWritingReadingMathFirst TimeRe-test
TABE:

PSC Certificate ProgramCollegiate High SchoolOther (employment, WIA, etc.)
Name of Program:
CPT:

College Level MathOther
Other Test Referral:
Name of Test:
Program:
NOTE:

Exempt students may opt to take the common placement test to help identify where they need additional preparation. Regardless of the scores, they shall not be required to enroll in developmental education. An advisor can provide further information on developmental education options.
Student Signature:

Clear
Driver's License

Cancelof
DD214

Cancelof
W-9

Cancelof
1040 Tax Forms

Cancelof
PERT Testing

Cancelof
Date

MonthDayYear
mm-dd-yyyy

APPLICATION FOR SERVICES

STIPEND POLICY

INCOME VERIFICATION FORM

INDIVIDUAL EDUCATION PLAN

REQUEST for STUDENT TESTING Referral Form