Davis & Elkins College Upward Bound Application | Upward Bound

Student Name*

First Middle Last

Preferred First Name

Date of Birth*

Gender*

Social Security Number*

Home Phone Number*

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Student Cell Phone Number

Your High School*

Current Grade Level*

Are You a U.S. Citizen?*

Yes
No

Ethnicity*

Student Email*

Student Required Accommodations

How do you describe yourself as a person and as a student?*

Please list activities in which you are involved.*

What are your career/educational/college goals?*

Parent(s) or Guardian(s) Living In Your Home

Residential Guardian Name (1)

First Last

Residential Guardian (1) Relationship to Applicant

Residential Guardian Email (1)

Residential Guardian Home Phone (1)

Residential Guardian Cell Phone (1)

Earned a Bachelor's Degree?

Yes
No

Employer

Work Phone

Address

Same as Mailing Address Above

Residential Guardian Name (2)

First Last

Residential Guardian (2) Relationship to Applicant

Residential Guardian Email (2)

Residential Guardian Home Phone (2)

Residential Guardian Cell Phone (2)

Earned a Bachelor's Degree?

Yes
No

Employer

Work Phone

Address

Same as Mailing Address Above

To satisfy government policies, the taxable family income of a student must meet certain federal guidelines. The information requested below is necessary to determine program eligibility. This information will be used confidentially and used one time only. Please attach tax forms that confirm the adjusted gross and taxable incomes. Complete the following using your most recent tax form in which the applicant is claimed.

Tax Year

Adjusted Gross Income

Total Number Living in Household

Taxable Income

I do not file income tax due to:

Benefits Our Household Currently Receives (checkmark all that apply)

Supplemental Nutrition Assistance Program (SNAP)
Medicaid or Supplemental Security Income (SSI)
Temporary Assistance for Needy Families (TANF)
Special Supplemental Nutrition Program for Women, Infant, and Children (WIC)
Unemployment

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.

Required Forms

Drop files here or

Max. file size: 64 MB.

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 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.

Parent/Guardian Signature*

Student Signature*

100% Funded by two Title IV grants from the US Department of Education totaling $799,156 (Pendleton/Pocahontas $309,505, and Randolph/Barbour/Tucker $489,651), project services are free to eligible students. Upward Bound is an Equal Opportunity in Education project that is in compliance with Title IX, Section 504 of the Rehabilitation Act, and the Age Discrimination Act and does not discriminate on the basis of race, sex, color, national or ethnic origin, creed, ancestry, marital/family status, veteran status, sexual orientation, gender, gender identity, gender expression, pregnancy, religion, age, disability or blindness, or any other characteristic protected by federal, state or local law. Inquiries regarding Title IX and the filing of a complaint should be referred to the College’s Title IX Coordinator: Amy Kittle, Title IX Coordinator Phone: (304) 621-1316 Email: [email protected] For further information on D&E's notice of non-discrimination, please see https://www.dewv.edu/statement-of-nondiscrimination/

Student and Parent/Guardian

Davis & Elkins College Upward Bound Release for

I authorize the D&E UB Program staff to secure subsequent information or materials relative to my academic status, performance and abilities in my school and throughout my 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 also give permission for D&E UB to communicate with my parents or guardians regarding my academic, financial, social and disciplinary status in accordance with the Family Educational Rights and Privacy Act (FERPA).

I authorize the D&E UB to use photographs, likenesses, or video footage of me 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 name, high school, hometown or college(s) to be attended, and other future plans to accompany my photograph or video image in publicity pieces.

Student's Signature*

Date*

I agree to provide proof of any information submitted to D&E UB, upon request. I also agree to inform D&E UB of any changes in address, telephone number, medical issues, or guardianship.

My signature below gives permission for D&E UB to access my student’s transcripts and all school files and records. My signature also gives permission for D&E UB to obtain academic transcripts, attendance, discipline reports, progress reports, disability documentation, and standardized test records from the school my student is attending or have attended. This access is intended to provide D&E UB the means to track and support my student’s academic progress in accordance with the Program’s annual reporting requirements determined by the U.S. Department of Education and to communicate openly with target schools, counties, and staffs.

I give permission for my student to use transportation provided by D&E UB throughout their UB participation. I agree to assist with transportation, whenever possible. I understand staff will supervise students. I also give permission for my student to participate in all UB activities. I knowingly and voluntarily assume all such risks, both known and unknown, even if arising from the negligence or fault of D&E UB, and assume full responsibility for my student’s participation in the Program.

I authorize D&E UB to use photographs, likenesses, and video footage of my student in publicity pieces, including but not limited to, news releases, such as those issued to local newspapers; publications, such as newsletters; program recruiting tools, such as videos and brochures; and the program’s web page, Facebook, or other social media. D&E UB also has my permission to use their name, high school, hometown or colleges, and other future plans to accompany my student’s photograph or video image in publicity pieces. D&E UB will not release specific street or mailing addresses, e-mail or phone numbers of participants.

Guardian's Signature*

Date*