1. Full Name: Address: Student 2. Social Security Number: Date of Birth:

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3 1. Full Name: First Name MI Last Name Address: Number and Street City State Zip Code Student Cell Phone: ( ) - Home Phone: ( ) - Student 2. Social Security Number: Date of Birth: 3. Citizenship Status: U.S. Citizen Permanent Resident Other **If you are not a U.S. Citizen, but are a Permanent Resident, please provide us with a copy of your Resident Alien Card** **If you are not a U.S. Citizen or a Permanent Resident, but are in the process of establishing Permanent Residency, you will be asked to provide proof of your intent in order to be considered for admission into the Upward Bound program.** 4. What is your ethnicity? Hispanic or Latino Not Hispanic or Latino 5. What is your race? Mark one or more races to indicate what you consider your race(s) to be. Asian Black or African American Indian/Alaska Native Native Hawaiian/Other Pacific Islander White 6. Gender: Male Female I identify as 7. Current School: Current Grade Level: 8. If you are in 8 th grade, which high school will you be attending next year? 9. Which type of diploma are you working toward? Advanced Standard Applied Studies 10. Do you have an active Individualized Education Plan (IEP)? Yes No 11. Who if anyone encouraged you to apply? 12. What do you want to do after you finish high school? College Armed Forces Work Full-Time 13. Have you previously, or are you currently participating, in a Talent Search, Upward Bound, or Gear Up program? Yes No If yes, with which college or university was/is your program affiliated? FAMILY INFORMATION 14. Are you currently in foster care? Yes No 15. Do you live with both of your parents? Yes No 16. Marital Status of Parents: Married Widowed Separated Divorced Never Married 17. What is/are the name(s) of the person(s) with whom you live? Parent/Guardian 1: First Name Ml Last Name Relationship to you? (i.e. mother, guardian): Highest level of education: Some high school High School Diploma Some college Associate s Bachelor s Parent/Guardian 2: First Name Ml Last Name Relationship to you? (I.e. mother, guardian): Highest level of education: Some high school High School Diploma Some college Associate s Bachelor s

4 INCOME VERIFICATION Please complete the following items as it relates to your family income. If you are enrolled in foster care, you may skip this section: 1. Total number of people in your household: 2. What is your family s total TAXABLE INCOME: (This number is found on IRS Form 1040 Line 43, IRS Form 1040A Line 27 or IRS Form 1040 EZ - Line 6) If your family did not pay income taxes last year, indicate all of the services you received in the last year below: Social Security Unemployment SNAP Social Security Disability Worker s Compensation Veteran s Benefits TANF Free or Reduced Lunch (please circle which one) By signing below, I certify all information in this Income Verification section is true and correct to the best of my knowledge. Head of Household Signature Date Signed ACADEMIC INFORMATION Please circle any of the areas below that you feel you need or would like help. ACADEMIC CAREER AND COLLEGE PERSONAL SOCIAL/CULTURAL The Importance of Grades Career Exploration, Planning Personal Counseling Social/Cultural Activities Note Taking Career Site/Job Site Visits Self-Esteem Building Diversification Study Habits & Study Skills College Exploration Communication Skills Time Management College Campus Visits Relationships Academic Attitude SAT/ACT Preparation Goal Setting Communication with teachers SAT/ACT Fee Waivers Drug/Alcohol Education Course Selection Completion of College Application Decision-Making Tutoring College Application Fee Waivers Financial Aid In accordance with the Privacy Act of 1974 (Public Law No , 5 U. S.C. 552A), you are hereby notified that the Department of Education is authorized to collect information to implement the Upward Bound program under Title IV of the Higher Education Act of 1965, as amended (Pub. Law ,sec. 402C). In accordance with this authority, the Department receives and maintains personal information on participants in the Upward Bound program. The principal purpose for collecting this information is to administer the program, including tracking and evaluation participants academic progress. Providing the information on this form, including Social Security number (SSN), is voluntary; failure to disclose a SSN will not result in denial of any right, benefit, or privilege to which the participant is entitled. The information that is collected on this form will be retained in the program files and may be released to other Department officials in the performance of official duties. I understand that the Upward Bound staff will use the data provided with this application to assess my/my child s eligibility, in accordance with federal regulations. I specifically grant permission to Virginia Tech Upward Bound to obtain information from the school system regarding my/my child s academic and disciplinary record. Upward Bound Staff may obtain any and all information and documentation necessary for processing my/my child s application and for meeting federal performance and tracking reporting requirements. I certify that any information which I have provided herein is true and correct to the best of my knowledge. Student s signature Date Parent/Guardian Signature Date

5 LETTER OF RECOMMENDATION Directions: Please have this form filled out by a teacher, coach, religious leader, work supervisor, or anyone who can speak to your academic ability, desire to attend college, work ethic and/or character. Once complete, attach to Upward Bound application and return to your hall guidance counselor. Student Name: Recommender Name: In what capacity do you know this student? How long have you known the student? Do you consider this student to be college bound? Please explain. Please remember that applications must be complete in order to be reviewed for eligibility and admission. Be sure you have included: Completed Upward Bound Application Head of Household, Student and Parent/Guardian Signatures Recommendation Form Please return completed application to your hall guidance counselor, or mail to: TRIO Programs Virginia Tech 385 West Campus Drive Hillcrest Hall-Lower Level (0146) Blacksburg, VA For the following questions, please circle one of the following options for each question: 1. Do you believe this student is prepared for the college application process? Yes No 2. Have they taken classes that will prepare them for college-level work? Yes No 3. Are they willing to take personal responsibility for their actions? Yes No 4. Do they actively seek guidance from you as their counselor? Yes No 5. Has this student expressed concerns about their ability to pay for college? Yes No 6. When interacting with their peers, are they respectful of boundaries? Yes No 7. In their interactions with teachers, do they listen and follow their directions? Yes No 8. Do you recommend this student for the Upward Bound program? Yes No 9. In what ways do you think this program would be beneficial to this student? 10. Is there anything else that we should be aware of when considering this student s application for our program? Please be frank. 11. Please provide contact information should we find the need to follow up with you about this recommendation: Phone Number: Address: Signature: Date: