ࡱ> + 8Jbjbj ܪDhܪDh B jj"""."}6"""$it"% !"%%"jj7)))%^j)%))y4PM<{%H{>т0{݇&݇݇"#)##<"""""("""}%%%%݇"""""""""X 0: Upward Bound Participant Application - 91̽ - Instructions Students complete Part 1. Students complete Part 2 with parents/guardians. Parents/guardians complete Part 3. Students give Math, Science and English reference forms to their teachers to complete. Guidance Counselors complete the Guidance Counselor Recommendation form (yellow). Students return the completed application to high school counselor Counselors submit completed applications packets (including application, teacher references, and counselor form) to Upward Bound PART 1: STUDENT INFORMATION Name: ____________________________________________________________________________________ Last First MI Social Security Number: (Required) ____________________________ Mailing Address: _____________________________________________________________ City: ___________________________ State: _________ Zip: ___________________ Home Phone: _________________________ E-mail Address: __________________________________ Parent/Guardian Cell Phone:________________________Student Cell Phone:_____________________ School Currently Attending: _______________________________________________________________ Current Grade in School: 8th 9th 10th Age: ___________ Date of Birth: ______________________________  U.S. Citizen: Yes No Gender: Female Male Race/Ethnicity: American Indian/Alaskan Native Asian Black or African American Hispanic or Latino Native Hawaiian or Pacific Islander Caucasian Other ________________________ Which aspects of the Upward Bound Program are you most interested in? (Check all that apply) Tutoring ACT Preparation Career Information College Enrollment Assistance Financial Aid Assistance Academic Advising Study Skills Improvement Math Skills Improvement Reading Skills Improvement Writing Skills Improvement Other _______________________ What is your Grade Point Average (GPA)? ________ How many hours each week do you study? __________ What are you most likely to do after high school graduation? Get a job  Join the military  Attend a 2-year college  Attend a 4-year college  Other:___________________ PART 1: STUDENT INFORMATION (continued) Essay responses will be considered in making selection decisions. Please put thought and effort into your answers. Please share a little about yourself and your future dreams. (use additional paper if necessary) __________________________________________________________________________________________________ __________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________ Please explain what a good education means to you. (use additional paper if necessary) __________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Please describe how Upward Bound could contribute to your future success. (use additional paper if necessary) __________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ PART 2: PARTICIPANT AGREEMENT Signatures of both the applicant and the parent(s)/guardian(s) are required in order for the application to be processed. Please read the agreement carefully prior to signing. The 91̽ Upward Bound Program will strive to provide students with academic resources and guidance, educational and social activities, and a positive learning environment in order to increase student motivation and effort. Our goal is to help students complete high school successfully and enroll in a post-secondary educational program. Upward Bounds educational support includes bi-weekly school visits during the academic year to mentor students and monitor their academic process. Upward Bound provides tutoring at all schools to help ensure student success. Upward Bound also conducts a six-week summer academic enrichment program on the 91̽ campus. In addition, Upward Bound provides ACT preparation assistance, cultural enrichment activities, campus visit opportunities, and a variety of field trips and travel opportunities. Students participating in Upward Bound agree to commit themselves to the goals of graduating from high school and continuing in post-secondary education. If selected to be an Upward Bound participant, I would agree to: Participate in Upward Bound until high school graduation Observe the rules and regulations of Upward Bound Attend school regularly Not use tobacco products, alcohol, or other illegal substances Attend the Upward Bound summer program (attendance is required for first-year participants and is optional thereafter) Actively participate in Upward Bound activities including bi-weekly school visits with Upward Bound staff and monthly on-campus activities at 91̽ Enroll in high school courses required for admission to higher education programs Maintain a minimum 2.0 GPA (grade point average) throughout the program Achieve satisfactory academic progress in all classes Exhibit positive, friendly, cooperative and respectful behavior toward Upward Bound staff and fellow students Apply for admission to a post-secondary education institution by January of students senior year in high school Maintain communication with Upward Bound for six years after graduating from high school to report on academic progress and my education I understand and am willing to honor these commitments. I also understand that failure to abide by the Participant Agreement may result in dismissal from the 91̽ Upward Bound program. ______________________________________________________ _________________________________________ Student Signature Date ______________________________________________________ _________________________________________ Parent/Guardian Signature Date AUTHORIZATION TO RELEASE EDUCATIONAL INFORMATION I hereby grant permission for 91̽ Upward Bound to have access to my high school records including: Transcripts Names of parents/guardians Attendance records Grades Minnesota graduation standards Grade point average Individualized Education Plans Age Address Social Security Number Class rank Standardized test scores Conduct or discipline records Other diagnostic data such as psychological or learning skills assessment Family Portal/Student Vue Access I hereby grant permission for 91̽ Upward Bound to have access to my post-secondary school records including: Unofficial Transcript Academic Standing Enrollment Status Degree/Certificate Information Semester/quarter grades Financial Aid College grade level Most recent contact information I understand that the records Upward Bound requests will be used only for the purposes of meeting federal grant requirements and improving the quality of the Upward Bound program. This information will only be shared with the United States Department of Education. Student Signature:______________________________________________________________________________ Parent/Guardian Signature:_________________________________________________ Date:______________ PART 3: ELIGIBILITY & CONSENT (to be completed by parent/guardian) The U.S. Department of Education requires Upward Bound programs to certify the eligibility of each student selected. Student eligibility is based on family income and the level of education that parents have achieved. Please provide the information requests on this form. All information provided will be kept strictly confidential and will only be used to determine your student eligibility for Upward Bound. Questions about this Family Information Form should be directed to 91̽ Upward Bound Program Office (218) 755-3334. This family information section must be completed in full before a student will be considered for admission to the Upward Bound program. * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * FOSTER CARE CERTIFICATION Students who are or have been in Foster Care after the age of 13 are automatically eligible for Upward Bound participation. (By checking the box, Income Certification & Family Education are not needed) By checking this box I certify that the student applying for Upward Bound participation is or has been, since the age of 13, in foster care. Name of Certifying Individual:_______________________________Signature:________________________ Relationship to Applicant:____________________________________________________________________ * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * FAMILY INCOME CERTIFICATION Income Verification: Choose Method A or Method B (Dependent students need to use their parents income amounts.) Method A: Please indicate family/household taxable* income for 2021 $________________ Total number of dependents claimed on your 2021 Income Tax Form (including yourself) ______ --OR-- Method B: Using the chart below, indicate whether your family meets TRIO income guidelines. ( Our family income is at or below the levels indicated for our family size. ( Our family income exceeds the levels indicated for our family size. Federal TRIO Programs Taxable Income* Levels Annual Low Income Levels (Effective January 11, 2019 Until Further Notice) (Taxable Income is your income after deductions, NOT your gross income.)Size of Family Unity48 Contiguous State, DC and Outlying Jurisdictions1$19,3202$26,1303$32,9404$39,7505$46,5606$53,3707$60,1808$66,900Family units with more than 8 members, add the following amount for each additional family member: $6,810. *Taxable income is listed on line 15 of form 1040. I certify that all information provided on this application is true and correct to the best of my knowledge. Parent/Guardian Signature(s): ______________________________________________ Date: _____________ * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * FAMILY EDUCATION CERTIFICATION Natural or adoptive parent (if living with applicant): Name:__________________________________________________ Relationship to applicant:_____________________ Parents highest educational level completed: Some High School High School GED Some College AA/AS BA/BS Natural or adoptive parent (if living with applicant): Name:__________________________________________________ Relationship to applicant:_____________________ Parents highest educational level completed: Some High School High School GED Some College AA/AS BA/BS  Applicant is not living with neither natural parent(s) or adoptive parent(s) * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * PARENT/GUARDIAN STATEMENT OF AGREEMENT I agree to support my student in his/her endeavors for academic success. I agree to encourage my student to actively participate in the Upward Bound program. I agree to monitor the academic progress of my student. I agree to call the Upward Bound office at 218-755-3334 if I have questions about a scheduled activity. I agree that it is important that my student not only participates in Upward Bound during the academic year, but also during the summer component of Upward Bound. Parent/Guardian Signature(s): _______________________________________ Date: _____________ * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * PARENT/GUARDIAN STATEMENT OF CONSENT AND RELEASE FROM LIABILITY I, ___________________________________________ the parent/guardian of ______________________________, give my consent for my student to participate in the Upward Bound program sponsored by 91̽. I understand my student will be participating in enrichment classes, tutoring sessions, campus visits, and field trips. I understand that the University has not made any representations concerning the safety methods of travel to and from or the travel sites visited. I hereby agree, on behalf of myself and my student, to assume all of the risks in connection with my students participation in the Upward Bound program, including travel, and I agree to release Bemidji State from any and all liabilities and claims whatsoever arising in connection with my students program participation including travel. I agree that the laws of the State of Minnesota shall govern this Waiver & Release. 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