2024-25 UB Online Program Application

Please mark current school student attend?*

Highland Park High SchoolFree State High SchoolF.L. Schlagle High SchoolWyandotte High SchoolOther
Application Materials
Applications must be completed before a student can be considered for admission into the program. Some of the requested information will help us determine whether or not a student meets the criteria for entry into the program.
Application Submission
Please submit completed application and attach supporting documents (Application, Tax information, and Middle/High School Transcript) to: School Counselor or emailed to ub_ubms@ku.edu , ATTN: Mike Conley.
Student Information
Student's Name*

First NameMiddle NameLast Name
Does student have an email account?*

YesNo
Student's Email Address:*

Confirmation Emailexample@example.com
Student's Gender*

MaleFemaleOther
Student's SSN:*
Date of Birth:*

MonthDayYear
Date
Cell Phone Number:*
Enter 000-000-0000 if not available
Home Phone Number:*
Enter 000-000-0000 if not available
Student's Primary Home Street Address*

Street Address

Street Address Line 2

CityState

Zip Code
Is There a Secondary Address?*

YesNo
Student's Secondary Address*

Street Address

Street Address Line 2

CityState

Zip Code
U.S. Citizen:*

YesNo
Are You a Permanent Resident:*

YesNo
STUDENT ETHNICITY*

Hispanic/LatinoBlack/African-AmericanWhite/CaucasianAsianNative American/First NationNative Hawaiian/Other Pacific IslanderOther
Parental Information
With whom does the student live with full-time?*

MotherStepmotherFatherStepfatherFemale GuardianMale Guardian
Mother's Name:*
Stepmother's Name:*
Father's Name:*
Stepfather's Name:*
Female Guardian's Name:*
Relationship:*
Male Guardian's Name:*
Relationship:*
Primary Parent/ Guardian Contact Name:*
Primary Parent/Guardian Date of Birth*
mm/dd/yyyy
Work Phone:*
Enter 000-000-0000 if not available
Cell Phone:*
Enter 000-000-0000 if not available
Best Time To Contact:*

MorningAfternoonEveningPrefer Voice MailPrefer Text Message
Any other language than English spoken at home:*
Primary Parent/Guardian Email Address*

Confirmation EmailEnter: none@example.com if parent does not have email
First-Generation Eligibility Information
Has either parent/guardian graduated from college with a 4-year degree?*

YesNo
If yes, which parent/guardian?*
Degree(s) earned:*
Financial Eligibility Information
The Upward Bound Program at the University of Kansas and the United States Department of Education require all applicants to submit with their application a signed copy of their parent/guardian’s 1040 federal income tax form.
Total number in household (dependent + spouses):*
Did you file your income tax return? (Please mark Yes or No and complete section A or B below)*

Yes, you did file an income tax return. Please attach a photocopy of your most recent tax return signed to this application and complete Section A Below.No, you did not file an income tax return this year, please fill out Section B below.
A. Enter taxable income amount (1040 Line 15)*
B.Select one estimated taxable income range:*

$0- $23,475$23,476 - $31,725$31,726 - $39,975$39,976 - $48,225$48,226- $56,475$56,476 - $64,725$64,726 - $72,975$72,976 - $81,225
CERTIFICATION
I certify that all of the information provided on this application and in the Financial Eligibility section of the application is true and complete to the best of my knowledge. I understand that the University of Kansas Upward Bound Program may ask for proof of any information provided on this application, and I agree to provide the necessary documents. I understand that if I refuse to provide proof of any information given, the applicant may be denied acceptance into the Upward Bound Program.
Signature of Parent/Guardian:*

Clear
Date:*

MonthDayYear
Date
Enrollment Information
You will need to provide a copy of your transcript!
Current Grade:*
Current School:*

Current Class Schedule*

	Currently Enrolled
1
2
3
4
5
6
7
8

Academic Need Information

This survey contains a number of statements about student needs: Please give your honest opinions of how the Upward Bound program can meet your needs:*

	No Need	Some Need	High Need
To learn how to complete and turn in my homework on time
To get better grades in school
To take tests better with less anxiety
To organize my time, activities, and responsibilities better
Learn more about high school requirements for college
Listen better in class and ask more questions
To relate to and communicate better with my teacher
To identify, set and evaluate goals for the future
To Explore a variety of career opportunities
To learn more about job applications, resumes, and interviews
To learn more about the postsecondary admissions process
To prepare for exams like the ACT and SAT
To visit more colleges
To learn about college costs and how to pay for college

My academic goal is:*
My career goals are:*
Write a short paragraph stating how you would benefit from participating in the Upward Bound program:*
Educational Record Release
Consent of Release of Educational Information

I agree to the release of my/my student’s grades, standardized test scores and transcripts by my middle school and/or high school to the University of Kansas Upward Bound Program beginning on the date of application. I understand that the Upward Bound Program will also maintain records on my performance in program activities. I agree to the release of this information to staff members and the U.S. Department of Education.
Student's Name (First and Last):*
Parent/Guardian Signature:*

Clear
Date*

MonthDayYear
Date
Electronic Media Release
Release for Electronic Work, Photos, and Video

I authorize the Achievement and Assessment Institute and its four Centers (the Center for Educational Testing and Evaluation, the Center for Public Partnerships and Research, the Center for Educational Opportunity Programs, and Agile Technology Solutions) to use photos or videos of my child/children for the following purposes:
As illustration on project materials for educational purposes and on the websites of the Upward Bound program, the Achievement and Assessment Institute and its four Centers.*

YesNo
Permission to use child/children in project materials and on the website.*

I prefer that the Achievement and Assessment Institute and the four Centers use pseudonyms for my child/childrenI give the Achievement and Assessment Institute and the four Centers permission to use my child/children's real names
I hereby acknowledge that I am the parent/guardian of the below listed child/children. I hereby give the above permission, and I release the Achievement and Assessment Institute and the four Centers from any liability resulting from the publication of said photos, videos, or comments. I understand that all photography and video recording will be related to the work of the Achievement and Assessment Institute and its four Centers.
Student Name (First and Last Name):*
Date:*

MonthDayYear
Date
Parent/Guardian Signature*

Clear
Date:*

MonthDayYear
Date
Parental Consent to Participate
I hereby grant permission for my child,_______________________ , to participate in the University of Kansas Upward Bound program, which may include field trips, overnight trips, tutorial sessions, living in the residential halls, and physical activities. I also understand and acknowledge that transportation for field trips for academic enrichment sessions, conferences, overnight trips, and other activities will be provided by bus, van, train, airplane, or private car. Activities may include swimming, canoeing, horseback riding, and other activities. In consideration of the activities provided to my child, I hereby release the University of Kansas Upward Bound program and their employees from any claims of injury or damages arising out of my child’s participation. I accept responsibility for my child’s conduct while participating in the Upward Bound Program, and I hereby release the Upward Bound Program from injuries or damages resulting from my child not following and adhering to the rules and policies of the program.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Student Contract
We agree that all the information contained in this application is true and correct. I understand that my guidance counselor should attach a copy of my school grades and test scores before sending my application. In addition, I pledge that if I am accepted into the University of Kansas Upward Bound Program, I will conform to the following requirements:

1. I will abide by all rules and policies of the program.

2. I will attend Saturday Enrichment Sessions, Summer Institutes, and other required events on a regular basis.

3. I will strive to continually improve my high school course grades.

4. I will make every effort to pass all high school course work.

5. I will cooperate with faculty, staff, and other students in the program.

6. I will make every attempt to remain in the program for the remainder of my high school education.

7. I will enter a postsecondary educational study program upon completion of the Upward Bound Program.
Student Signature:*

Clear
Parent/Guardian Signature:*

Clear
Date:*

MonthDayYear
Date
Medical Form
CONFIDENTIAL HEALTH RECORD
Student's Name:*

First NameMiddle NameLast Name
Student's SSN:*
Student's Gender*

MaleFemaleOther
Birthdate:*

MonthDayYear
Date
Student's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent's/Guardian's Name:*
Home Phone:*
Enter 000-000-0000 or NA
Person to be notified in case of an emergency (if other than above):*
Enter NA if Not Applicable
Emergency Contact Day Phone #:*
Enter 000-000-0000 if not available
Emergency Contact Evening Phone #:*
Enter 000-000-0000 if not available
Do you have any significant illness or disability? If Yes, please explain below*

YesNoOther
Have you had any other significant illness, injuries, and or surgery in the past? If Yes, please explain below:*

YesNoOther
Are you allergic to any medication, or do you have any allergies? If Yes, please list medications, and or allergies below:*

YesNoOther
Are you under medical care, including current prescriptions? If Yes, please explain below*

YesNoOther
INSURANCE RELEASE
Does the student have health insurance coverage?*

YesNo
Name of Insurance company*
Insurance Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Policy Holder*
Relationship of student to policy holder:*
Policy holder group number:*
Enter: Not Available if Unknown
Policy Holder individual ID Number:*
Enter: Not Available if Unknown
Street Address of Policy Holder*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
MEDICAL RELEASE
I hereby authorize Watkins Health Center and/or Lawrence Memorial Hospital to release primary and secondary diagnoses and/or accident details to the provided insurance company. If there is no company listed, release information to Upward Bound’s summer insurance provider as necessary. Also, release information presenting my claim for benefits, as requesting by such company for the purpose of considering my claim.

Student’s Signature: Parent’s/Guardian’s Signature:
Student's Signature:*

Clear
Parent's/Guardian's Signature:*

Clear
I hereby authorize payment directly to Watkins Health Center and/or Lawrence Memorial Hospital of the benefits otherwise payable to me. I understand that I am financially responsible to Watkins Health Center and/or Lawrence Memorial Hospital for charges not covered by insurance.
Parent's/Guardian's Signature:*

Clear
*Note Watkins Health Center is NOT a Medicaid provider! I hereby grant permission for the Upward Bound Program at the University of Kansas to give medical treatment when needed and to provide any necessary routine and emergency medical and dental service for the entire period that my child is enrolled in the Upward Bound Program. I will not in any way, hold the University of Kansas or the Upward Bound Program responsible for any treatment deemed necessary for medical or dental services.
Parent's/Guardian's Signature:*

Clear
Please attach a copy of your official transcript here.*

Browse Files

Cancelof
Please attach a copy of Financial Eligibility Information such as 1040, pay stub etc.*

Browse Files

Cancelof
Forms that need to be attached to application:*

Financial Eligibility Information: 1040 tax returnHigh School Transcript
Should be Empty:

Application Materials

Application Submission

Student Information

Parental Information

First-Generation Eligibility Information

Financial Eligibility Information

CERTIFICATION

Enrollment Information

Academic Need Information

Educational Record Release

Electronic Media Release

Parental Consent to Participate

Student Contract

Medical Form

CONFIDENTIAL HEALTH RECORD

INSURANCE RELEASE

MEDICAL RELEASE