To be considered for the Upward Bound program, all applicants must complete an application in its entirety. Supporting documentation must be submitted as well i.e. the prior year W2 and the most recent report card.  Additionally, all applicants will need a recommendation form from their English Teacher, Math Teacher, and School Counselor. An interview will not be scheduled without the requested verification documentation.

• I authorize and give permission to the West Virginia State University Upward Bound staff to access and/or receive copies of my academic transcripts, progress reports, schedules, report cards, standardized test scores, SAT, ACT, PSAT, and PLAN test scores, post-secondary enrollment status, attendance reports, or any other information needed to access and monitor my academic progress.

• I authorize my middle and/or high school couselors, teachers, or other administration to release these records to the West Virginia State University Upward Bound program from the date signed below through post-secondary graduation.

• I authorize the West Virginia State University Upward Bound staff to talk, email, or correspond with teachers, instructors, counselors, and other school administrators at my child’s school in order to obtain and exchange information as part of the service provided by the Upward Bound program.

• I authorize the West Virginia State University Upward Bound staff to access and monitor my chid's academic progress through school learning platforms to include, but not limited to, Schoology, Livegrade, Engrade, etc.

A photocopy of this record release form should be accepted as an original and the date signed has no bearing to the date that West Virginia State University Upward Bound program staff request the information.

The principle purpose for collecting this information is to administer program services, including tracking and evaluating participant’s academic progress.  The information collected on this form will be retained in the program files and may be released to Department of Education officials in the performance of official duties.  In accordance with the Privacy Act of 1974 (Public Law No. 93-57, 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 102-325, sec3 402C).  All information is handled in a confidential manner as protected by law.

Please write an essay explaining why you would like to be selected for the Upward Bound Program at West Virginia State University. In your essay, be sure to include the following:

1. Your educational and career goals after high school.

2. Any problems that may keep you from achieving these goals.

3. Why should you be selected for the TRIO Upward Bound program?

By signing below, I certify that the information provided in this application is true, complete, and accurate to the best of my knowledge. I understand that, if selected, my child is expected to participate regularly in all Upward Bound program activities, including Saturday sessions and summer components, and to remain actively involved throughout high school until graduation and enrollment in a college or university.

This information is necessary to ensure that the applicant meets the criteria for admission to Upward Bound as established by the U.S. Department of Education. All information on this application is handled in a confidential manner as protected by law.

Medical Authorization Acknowledgement & Agreement

This completed form will be photocopied for out of state trips and other activities when the parent/legal guardian is not present. I understand that while all reasonable efforts will be made to provide a safe environment, certain risks are involved. In consideration for the opportunity to participate in the activity, I understand the state of West Virginia, West Virginia State Univerisy, it's Board of Governors, officers, employees, agents, and volunteers are not liable in case of accidental injury or illness. I hereby further understand that in case of serious injury or illness, I will be notified. If it is not possible to contact me, I hereby give permission for emergency treatment or surgery as the attending physician recommends.

• I hereby give permission to West Virginia State University Upward Bound staff to seek emergency medical treatment, including ordering x-rays or routine tests, and assume the responsibility of all medical bills, if any.

• I agree to the release of any records necessary for treatment, referral, billing, or insurance purposes.

• I give permission for West Virginia State University Upward Bound staff to arrange necessary related transportation for my child in the event I cannot be reached in an emergency.

• I hereby give permission to the physician selected by the West Virginia State University Upward Bound staff to secure and administer treatment, including hospitilization, for my child named above, and assume the responsibility of all medical bills.

• I understand that should a health emergency arise, I will be notified as soon as possible, and medical treatment as deemed necessary by medical personnel is authorized.

• In consideration for being accepted by West Virginia State University for participation in the Pre-College Upward Bound program, I (we), being 21 years of age or older, do for myself (ourselves)(and on behalf of my child) do hereby release, forever discharge, and agree to hold harmless West Virginia State University, West Virginia State University staff, administrators, and Board of Governors thereof from any and all liability, claims or demands for personal injury, sickness, or death, as well as, property damage and expenses of any nature whatsoever  incurred by the undersigned and the child  while said child is participating in the above described program.

• Furthermore, I (we) on behalf of my (our) child hereby assume all risk of personal injury, sickness, death, damage, and expense as a reult of participation in recreation and work activities involved there in.

• Further, authorization and permission is hereby given to said program to furnish any necessary transportation, food, and lodging for participant.

• The undersigned further herby agrees to hold harmless and idemnify said university, its administrators, and employees for any liability sustained by said initiative as the result of negligent, willful, or intentional acts of said participant, including expenses incurred attendant hereto.

• Further, should it be necessary for the participant to return home due to disciplinary action or otherwise, I (we) hereby assume all transportation costs.

• I (we), the parent(s) or legal guardian(s) of this participant, heby grant my (our) permission for him/her to participate fully in the West Virginia State University Upward Bound program.

I hereby give my consent for the image and likeness of the named below participant in Upward Bound to be videotaped, audiotaped, or photographed for the following uses: Educational/Instructional, Recruitment/Outreach, Development, and Newsworthy media documentation.

• I further authorize West Virginia State University and/or West Virginia State University Upward Bound to use this electronic media and/or photographs in any manner-whole, or in part. This waiver includes usage of this media in any way deemed appropriate, which may include electronic and photographical reproductions thereof for the production of educational, instructional, promotional, or institutional advancement materials, which support the educational and outreach activities of West Virginia State University and/or Upward Bound.

• I hereby waive any right I may have to inspect or approve any use of this electronic media and/or photographs, and I release West Virginia State University and its component parts from all liability which could result from its use.

• I understand that West Virginia State University media and other publications may feature the Upward Bound program or highlight participant's achievements or accomplishments. I further understand that West Virginia State University staff cannot be held responsible if others take photos, video tape, or audio record participants at events.