Davis & Elkins College-UB 1-2025 Application Form

Thank you for your interest in applying to the Davis and Elkins College Upward Bound Programs. This is a program dedicated to helping high school students achieve their dreams of attending and graduating from college. Please have both the student and guardians fill out the following applications as fully as possible - both will need to sign the application. You can save your information and come back later to complete it if needed.

Once you submit the application, you will receive an email confirmation of your submission. Our staff will follow up with you after we receive your application to complete the application process. If you have any questions, please call 304-940-3610 or email us at deupwardbound@dewv.edu

Name

First NameLast Name

School student attends

Student's grade level for the current academic year

Student's Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Student's Home Phone Number

(999)999-9999

Student's Cell Number

(999)999-9999

Student's Email Address

example@example.com

Do you have internet access at home?

Student's Social Security Number

999-99-9999

Please enter your Social Security # again below

999-99-9999

Student's Date of Birth

mm-dd-yyyy

Citizenship Status Students must be U.S. Citizens or Permanent Residents to be eligible for Upward Bound

Student's Gender

The United States Department of Education requires our program to collect data on participants' race and ethnicity.

Student's Ethnicity (Select all that apply)

Please indicate languages, other than English, spoken at home:

Please list all co-curricular and other activities in which student is involved, both inside and outside of school. (Examples include: work, athletics, band, student government, clubs, community or church groups, hobbies, or other organizations)

What was your grade point average (GPA) at the end of last semester?

Do you want to go to college after you finish high school?

List 3 careers that interest you. (Things you would like to do after you complete college.)

Please write a brief paragraph about why you want to be an Upward Bound student and how Upward Bound can help you.

Are you willing to complete and participate in online tutoring and virtual programming?

Are you willing to participate in college visits and academic or extracurriculur events on weekends?

Are you willing to commit to participate in activities held on the campus of Davis & Elkins College?

Are you willing to participate in an activities held during the summer residential academy?

How did you hear about Upward Bound?

What made you want to apply to Upward Bound?

I (the student) understand that a failure to follow the Upward Bound Code of Conduct could result in dismissal from the program at any time.

Date

mm-dd-yyyy

I (the student) give my permission for the Upward Bound Program to use my image/likeness in or on Upward Bound related publications and/or public relations materials. I understand that these items will be used to provide information about UB services and activities. This may include: Newsletters, Videos, Website, Handbook, Brochures, Newspaper and all social media sites.

Date

mm-dd-yyyy

With whom does the student live?

Parent Marital Status

Please list names of all the persons who live in the student's primary household (including yourself)

Parent/Guardian (1) Full Name

First NameLast Name

Parent/Guardian (1) Relationship to the Student

Parent/Guardian (1) Student resides with me ____ % of the time

Parent/Guardian (1) mailing address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian (1) home phone number

(999)999-9999

Parent/Guardian (1) mobile phone number

(999)999-9999

Parent/Guardian (1) Education (check highest level completed):

Parent/Guardian (1) Occupation

Parent/Guardian (1) Employer

Parent/Guardian (1) work phone number

(999)999-9999

Parent/Guardian (1) Email

example@example.com

Parent/Guardian (2) Full Name

First NameLast Name

Parent/Guardian (2) Relationship to the Student

Parent/Guardian (2) Student resides with me ____ % of the time

Parent/Guardian (2) mailing address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian (2) home phone number

(999)999-9999

Parent/Guardian (2) mobile phone number

(999)999-9999

Parent/Guardian (2) Education (check highest level completed):

Parent/Guardian (2) Occupation

Parent/Guardian (2) Employer

Parent/Guardian (2) work phone number

(999)999-9999

Parent/Guardian (2) Email

example@example.com

The information requested below is necessary to determine program eligibility. This infromation will be used confidentially andis held to strict security standards and used only one time to evaluate eligibity. Please complete the following using your most recent tax form in which the applicant is claimed.

Did the Parent/Guardian(s) of this student file a federal tax return?

Tax Year

Adjusted Gross Income

Total Number Living in Household

Taxable Income

Select if applicable:

Benefits Our Household Currently Receives (check all that apply)

Special/Unusual Circumstances

Sometimes there are conditions that occur after filing taxes, and the taxes no longer accurately reflect a family's financial situation (i.e.loss of income, reduction of work hours, loss of benefits, long-term illness/disability, death of spouse/custodial/parent, abandonment, incarceration, etc). If this has occurred with your family, please explain your special/unusual circumstances.

Space needed

Please upload a copy of your most recent tax return

Upon signing this application, I certify that this information is true and correct to the best of my knowledge and understand that this information will be used as a tool to determine my childs eligibility to participate.

I certify that all the above information is correct to the best of my knowledge. I agree to provide proof of any information submitted to the Upward Bound Program, upon request. I also agree to inform the Program of any changes in address, telephone number, medical issues, or guardianship. I give permission for the Davis & Elkins College Upward Bound to access my son's or daughter's transcripts, school files, and to communicate openly with staff.

Are you willing to allow and support your child to participate in Upward Bound during both the academic year and summer program?

My child is currently being served or provided accommodations at school through an IEP, 504 Plan, or because of a disability or something else to support their education. If applicable, please explain in the box below.

Are you willing to allow and support your child to participate in the summer residential program at D & E?

I authorize and understand that the D&E UB Program staff will work to secure subsequent information or materials relative to my child’s academic status, performance and abilities in my school and throughout my child’s academic endeavors.

I also understand that my signature gives permission for D&E UB to obtain academic transcripts, attendance, discipline reports, progress reports, disability documentation, standardized test records, or enrollment status from my high school or the school of postsecondary education that I am attending or have attended. This access is intended to provide D&E UB the means to track my academic progress in accordance with the Program's annual reporting requirements determined by the U.S.Department of Education and to communicate openly with schools and postsecondary institutions.

I authorize the D&E UB to use photographs, likenesses, or video footage of myself or my child in publicity pieces including, but not limited to, news releases, the Program's web page, Facebook, or other social media. I also authorize UB to use my child’s name, high school, hometown or college(s) to be attended, and other future plans to accompany photographs or video images in publicity pieces.

I understand that the project is 100% funded by a title IV grant through the US Department of Education with project services being free to eligible students.

Guardian's Name

First NameLast Name

Guardian's Signature

Do you have any questions or concerns that you would like to ask or note of the program? Please list these in the box below.

Date

mm-dd-yyyy

Davis and Elkins College Upward Bound

PARENT/GUARDIAN SECTION