Washburn University Of Topeka-UB-Application Form

Washburn Upward Bound Topeka High School
Washburn Upward Bound Topeka High School, Room 338 Topeka High School Email:
atubbs@tps501.org, Topeka High School Office Phone: (785)295-3220
Student Full Name:*

First NameLast Name
Student TPS501 Email Address:*
example@example.com
General Information
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone:*
(999)999-9999
Home Phone:*
(999)999-9999
Emergency Phone:*
(999)999-9999
Date of Birth:*

MonthDayYear
mm-dd-yyyy
Gender:*
He/HimShe/HerThey/Them
YesNo
If yes, please provide a copy of your birth certificate.

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If No, Registration Card #:
Please provide a copy of your Registration Card

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Immigration Status:
YesNo
YesNo
Please Specify Disability:
Education Information
YesNo
8th grade9th grade10th grade11th grade12th grade
If in 8th grade at time of this application, please provide the name of your current middle school*
Anticipated Graduation Year:*
YesNo
YesNo
YesNo
College TripsCultural ActivitiesTutoringCultural TripsAcademic CounselingPersonal CounselingVocational/Career CounselingWorkshopsSAT Prep
2-Year CollegeMilitaryTraining SchoolVo-Tech4-Year College
Family Information
1st Parent/Guardian’s Name:*

First NameLast Name
Phone Number:*
(999)999-9999
Email:*
example@example.com
YesNo
YesNo
FatherFoster ParentGrandparentLegal GuardianMotherOther RelativeStep Parent
2nd Parent/Guardian’s Name:

First NameLast Name
Phone Number:
(999)999-9999
Email:
example@example.com
YesNo
YesNo
FatherFoster ParentGrandparentLegal GuardianMotherOther RelativeStep Parent
Income Information
I/we have completed and submitted a federal income tax return for the most recent reporting year.I/we have completed and submitted a federal income tax return for the most recent reporting year but respectfully decline to provide a copy.I/we have not completed and submitted a federal income tax return for the most recent reporting year nor will I/we.
Please attach a copy of the 1040 federal income tax form

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$0 – 22,590$22,591-30,660$30,661-38,730$38,731-46,800$46,801-54,870$54,871-62,940$62,941-71,010$71,011-79,080More Than $79,080
Occupation (s):*
Place (s) of Employment:*
# People in Household:*
# Person (s) in Household Working:*
Child SupportEmploymentPublic AssistanceSocial Security Insurance (SS)Supplemental Income
Statistical Information
AsianBlack/African AmericanNative Hawaiian or Other Pacific IslanderOtherAmerican Indian or Alaska NativeWhite
YesNo
YesNo
YesNo
YesNo
YesNo
Have you been previously enrolled in Upward Bound Program: If so, where?*
Have you been previously enrolled in Talent Search: If so, where? *
Have you been previously enrolled in Upward Bound Math and Science Program: If so, where?*
Student Questionnaire Information

Please answer all questions to the best of your ability
What do you like and/or dislike about school?*
What is (are) your best subject (s)? Why?*
What is (are) your worst subject (s)? Why?*
What do you want to study in college? Why?*
What are your special interests, skills, talents, or hobbies?*
YesNo
Saturday Academy is offered once a month at Washburn University from 8:30am-1pm, food provided.
YesNo
YesNo
$60 stipends are provided to students who attend 4 out of the 6 weeks.
YesNo
YesNo
If yes, where:*
What extracurricular activities are you involved in: *
Why do you wish to join the Upward Bound Program? Please write a short paragraph and state your short-term goals.*
Please state your long-term goal (what do you hope to accomplish in terms of your future educational and career goals?).*
Signatures of Acknowledgement
All of the information on this Confidential Application is true and correct to the best of my knowledge. If I am asked, I will agree to give proof (verification and documentation) that will validate the truth of the information provided in this application.

I, understand that if I purposely give false or misleading information on this application, I may be subject to expulsion from the Upward Bound program.
Student Signature: *

Clear
Date*

MonthDayYear
mm-dd-yyyy
1st Parent/Guardian Signature:*

Clear
Date*

MonthDayYear
mm-dd-yyyy
2nd Parent/Guardian Signature:*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Questions or Concerns Contact:

Ameshia Tubbs, Upward Bound Advisor

Washburn University Office Phone: (785) 670- 1218

Washburn University Email: ameshia.tubbs@washburn.edu

Topeka High School Office: (785)295-3220

Topeka High School Email: atubbs@tps501.org

Washburn Upward Bound Topeka High School

General Information

Education Information

Family Information

Income Information

Statistical Information

Student Questionnaire Information

Signatures of Acknowledgement