Upward Bound Program Student Application (2017-2018) Dear Parent(s)/Guardian(s) and Prospective Student: The Upward Bound Program of the Greater Erie Community Action Committee (GECAC) in collaboration with Edinboro University of Pennsylvania is designed to provide an opportunity for eligible high school students to succeed in their overall pre-college performance and ultimately higher education pursuits. The mission of the program is to increase the rates at which participants enroll in and graduate from institutions of post-secondary education. Upward Bound is a federally funded TRIO program that provides all services FREE to eligible students. Program services include: ~ Bi-monthly instruction in math; laboratory sciences; composition and literature; and foreign language(german) by certified high school teachers ~ Six-week summer residential experience on the Edinboro University of PA campus ~ Academic, financial, and/or personal counseling ~ Academic programs and cultural activities ~ Tutorial services and study skills enrichment programs ~ Fieldtrips to colleges ~ Information on post-secondary options and opportunities ~ Assistance in completing college entrance exams ~ Standardized test and college application fee waivers ~ Financial aid awareness and financial aid opportunities ~ College Bridge program for graduating seniors ~ Stipends and additional incentives for successful participation Application may be returned to the school guidance office or mailed to the address below: GECAC Upward Bound Program 18 West Ninth Street Erie, PA 16501 www.gecac.org For additional information on the Upward Bound Program, please call (800) 769-2436/ (814) 459-4581, extension 676 Thank you for your interest in the Upward Bound Program. Participants are accepted into the GECAC Upward Bound Program without regard to race, national origin, religion, gender and/or disability.
Upward Bound Program: Student Application Have you previously applied for & been accepted into the program? Yes No If yes, do not apply again. Contact the Program staff at GECAC. Are you currently participating in Talent Search or Upward Bound Math/ /Science program? Yes No I. STUDENT INFORMATION (Please Print in blue or black ink) Name: (First) (Middle) (Last) Mailing Address:. City: State: Zip:. Telephone: ( ) and/or ( ) Social Security Number (REQUIRED): - - Student E-mail (optional): Date of Birth: / / Age: Gender: Male Female Are you a U.S. citizen? Yes No If No, what is country of permanent residency? Alien Registration Card Number: Ethnic Background (if multi-racial, please check all that apply): African American/Black Asian American Caucasian/White Latino/Hispanic Native American Pacific Island II. EDUCATION OF APPLICANT Current high school Current grade level: 9 10 11 12 Expected graduation year See your guidance counselor for current: G.P.A. QPA
III. Confidential Family Information To be completed by a parent/guardian. The GECAC Upward Bound Program is funded by the U.S. Department of Education that requires documentation on specific statistics about the students we serve. Please complete Parts 1-3 below and sign where requested on the last page. Please do not hesitate to contact us if you have any questions. All information on this form is STRICTLY CONFIDENTIAL and will be used for statistical purposes only. Part 1: (Please check all information that applies) Who does the student live with? Father Mother Stepfather Stepmother Other Please check education level attained: Father: 0 8 9 12 (non-graduate) high school/ged graduate graduate plus some postsecondary 4-year college graduate Mother: 0 8 9 12 (non-graduate) high school/ged graduate graduate plus some postsecondary 4-year college graduate Part 2: (Please complete all information) Do you: Own your home? Pay Rent? Stay with Others? Number of people in the household. Your family may be eligible for additional services by providing information for all other individuals living in the household. Please use additional sheet for more than 6 members. First & Last Name Social Security Number Date of Birth Individual income Relationship Head of household Does the family have health insurance? Direct Purchase Employment Based Medicare State CHIP State Ins.for Adults Other No What is the source of income? Employment TANF SSI Child Support Social Security Pension Unemployment Disability General Assistance Does family receive any other source of income such as? Food stamps Medicaid WIC Subsidized Day Care Subsidized Housing At school, does your child receive: Free Lunch Reduced lunch Is your child a former GECAC Head Start Program student? Yes No
Did you file a federal income tax return last year? Yes No (If no, go to part 3) Check below the appropriate yearly taxable income category from last year. Refer to IRS Form 1040 ~ line 43, 1040A ~ line 27, 1040EZ ~ line 6. Less than $18,090 (1) $36,901 - $43,170 (5) $61,981 or above $18,091 - $24,360 (2) $43,171 - $49,440 (6) $24,361 - $30,630 (3) $49,441 - $55,710 (7) $30,631 - $36,900 (4) $55,711 - $61,980 (8) Please explain any additional circumstances (i.e. extraordinary family expenses, handicap, disability, job loss, etc.) to be considered for eligibility in the Upward Bound Program. Use additional sheet if necessary. Upward Bound (UB) is a challenging program that assists students for enrollment in either a 2- year or a 4-year college or university. UB has limited vacancies each year and specific student expectations that will be monitored: Regular attendance in school Regular Saturday program attendance Improved grade point average each grading period Commitment to full participation during the six-week summer residential component at Edinboro University. Participation in class and program activities Respect for all individuals Appropriate behavior in school and Upward Bound Student Response: Please write why you should be part of Upward Bound and what you intend to accomplish while in the program. Parent/guardian expectations
Are you aware that Upward Bound is a multi-year commitment with the ultimate goal of your student enrolling in college immediately after high school? If your student is accepted into the program, are you willing to support him/her by: Encouraging regular school and UB program attendance Attending mandatory student and parent meetings when scheduled Providing transportation for your child to and from UB activities if necessary Communicating with UB staff when necessary If we need to contact you, it will be during regular GECAC business hours (8:30am to 4:30pm) Please list all numbers that staff may contact you at. Number: work home cell Number: work home cell Number: work home cell Parent/Guardian E-mail: Emergency Contact (other than Parent): Phone: Relation: APPLICATION CHECKLIST Please check each item below as it is completed before submitting application Phone Number Social Security Number (9 digits) Information on individuals in the household Educational status of mother and/or father Income Information Health Insurance Information Student Signature Parent Signature Official School Transcript Two Teacher Recommendation Forms (Forms from any other individuals (family members, friends) WILL NOT be accepted). I certify that the family and financial information is true, correct, and complete to the best of my knowledge. Parent's/Guardian Name (print): Parent's/Guardian Signature: Date: Student Signature: Date: UB Counselor s Signature: Date: ~Sponsored by~ GECAC ~Funded by~ U.S. Department of Education ~Hosted by~ Edinboro University of PA FOR OFFICE USE ONLY STATUS: [ ] LI/FG at Risk [ ] LI/FG [ ] LI at Risk [ ] LI Only [ ] FG at Risk [ ] FG Only [ ] O Upward Bound Director Signature.. Date
GECAC Upward Bound Records Release Form Please complete this form and return it with your application. By signing this release form, I agree to allow the Greater Erie Community Action Committee Upward Bound program to obtain academic records, i.e. grade reports, transcripts enrollment information, IEP s, test scores and any other relevant educational information for purposes of program evaluation from any high school or post-secondary institution that I attend. This information will be handled in strict confidence according to federal regulations. Student s Name (Please Print) Year of High School Graduation Signature of Parent or Guardian Date Student Signature Date