University Of Wisconsin-Milwaukee-VUB-Application Form

Veterans Upward Bound Application
Completion of the following is required for reporting and verification purposes. Responses are kept confidential and are only shared with the Department of Education per reporting requirements. As a grant recipient of the US Department of Education, Veterans Upward Bound (VUB) is committed to the guidelines provided under The Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. § 1232g; 34 CFR Part 99) which is a Federal law that protects the privacy of student education records. Veterans Upward Bound will not disclose your personal identifiable information to any third-party without your prior written consent. Please answer each section accurately and completely.
Legal Name*

First NameLast Name
Date of Birth*

MonthDayYear
mm-dd-yyyy
Sex*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Secondary Email
example@example.com
Cell Phone*
(999)999-9999
May we text you?*

YesNo
U.S. Citizen or Permanent U.S. Resident?*

YesNo
Ethnic/Racial Origin. Hispanic/Latino?*

YesNo
Please select on of these five choices*

American Indian/Alaskan NativeAsianBlack/African AmericanWhiteNative Hawaiian/ Other Pacific Islander
Are you receiving VA Disability?*

YesNoClaim Submitted
The number of individuals currently living in my household and/or claimed as dependents (including yourself) is:*

123456789+
Employment Status*

Full timePart TimeUnemployedRetired
Instructions:

Make sure you only use your taxable income.

To determine your taxable income, refer to your last federal tax return. It is your income after all of your deductions.
Taxable Income:*

No taxable income$1 - $23,475$23,476 - $31,725$31,726 - $39,975$39,976 - $48,225$48,226 - $56,475$56,476 - $64,725$64,726 - $72,975$72,976 - $81,225$81,226 or above
MILITARY SERVICE
Select one of the following:*

Served on active duty as a member of the U.S. Armed Forces for more than 180 days and was discharged or released under conditions other than dishonorable; orServed on active duty as a member of the U.S. Armed Forces and was discharged or released because of a service-connected disability; orWas a member of a reserve component of the U.S. Armed Forces and was called to active duty for more than 30 days; orWas a member of a reserve component of the U.S. Armed Forces who served on active duty in support of a contingency operation on or after September 11, 2001.
Branch of service (Choose one)*

ArmyNavyAir ForceMarinesCoast GuardSpace ForceNational GuardReserves (For all branches)
Type of discharge (Choose one)*

HonorableGeneralOther than honorableBad conductDishonorable
Date Entered Service*

MonthDayYear
mm-dd-yyyy
Date of Separation*

MonthDayYear
mm-dd-yyyy
Do you have military education benefits?*

YesNoUnsure
Please list which education benefits below*
EDUCATION INFORMATION
Do either of your parents have a 4-year degree attained in the United States?*

YesNo
Highest education level completed:*

Diploma/GEDSome collegeCertificate/otherAssociate's degreeBachelor's DegreeMaster's DegreePhD
Have you been out of school for 5 or more years?*

YesNo
Are you currently enrolled or attending school?*

YesNo
Date Started?*

MonthDayYear
Date
Are you confident in completing a college application?*

YesNoUnsure
Do you have an idea of what federal and/or state education benefits you may qualify for and where to get additional information?*

YesNoUnsure
Do you understand how to apply for FAFSA and how it works with VA education benefits?*

YesNoUnsure
Do you know where to find tutoring or academic support on campus?*

YesNoUnsure
Do you know where to find support services like academic advising, mental health counseling, or disability services?*

YesNoUnsure
Academic Need: (Select all that apply)*

Need established in one or more at risk fields.Need for refresher coursesCareer aspirationsLack of supportLack of employable skillsLack of preparation for post-secondary enrollmentLack of preparation for PSE/continuationLack of confidence to transition into civilian life/PSELack of awareness of student financial aidLack of knowledge about military education benefits
Obstacles that may interfere with Class Attendance (Select all that apply)*

Health problemsUnclear Career goalsLack of motivationTransportationWork scheduleHomelessnessDepressionChemical dependencyChildcareEmployment SearchLoan DefaultOther
What is your field of Interest?*

ArtBusinessConstructionHealth SciencePublic ServiceEducationScienceSocial ScienceTechnologyTransportationRepairsTradeOther
STUDENT CONTRACT
How did you hear about Veterans Upward Bound?*

Community Agency (i.e. Employment Services)Veterans AgencyAdvertisement/Media (including mailings)Website/FacebookReferral (Educational Institution)Word of Mouth/Walk-inReferral (another TRIO program)Referral (non-TRIO program)Other
Link to handbook

I certify that I read the Veterans Upward Bound Student Handbook and agree to abide by the expectations outlined within the handbook while I participate in the program.
Signature*

Clear
I certify that the information on this form is true and accurate to the best of my knowledge. I also grant Veterans Upward Bound permission to obtain and review any academic documents needed to complete the application process and that is pertinent to my participation in the program. This may include certification of my prior and/or current school/college attendance.
Signature Box *

Clear
Date*

MonthDayYear
mm-dd-yyyy

Veterans Upward Bound Application

MILITARY SERVICE

EDUCATION INFORMATION

STUDENT CONTRACT