2024-2025 Upward Bound Application Christian

2024-2025

Upward Bound Christian Application
Murray State University TRiO Upward Bound Program

203 Blackburn Science Bldg. Murray, KY 42071 phone 270.809.2059
Dear Parent(s)/Guardian(s):

Thank you for your interest and taking the time in filling out the application completely and legibly to Upward Bound Murray State University. Once we receive the application is received your son or daughter will be considered by Upward Bound as a participant. We appreciated you providing confidential and personal information and we will abide by the Family Education Rights and Privacy Act of 1974, which states we will keep all information confidential.

Participants are selected by the following:

Section I

*Application filled out completely
*One letter of recommendation from counselor, and two recommendations from a teacher (These forms are seperate and can be emailed or given to counselor/teacher)
*An interview held by the UB staff with student and parent(s) or guardian
*Current GPA of 2.5 or higher, current report card, high school transcript (information obtained from counselor

Section II

Once application is complete the process is the following:

*Student will return application to Upward Bound staff
*Upward Bound staff will then contact you to set up interview mentioned above in section I with student and parent(s) or guardian.
*Student will receive from Upward Bound an acceptance letter if accepted
*Student will receive program information and Remind access (program to inbox and text questions)

Students remain in upward bound all through their high school years. Providing the following:

*Meet the GPA requirements 2.5 or higher
*Student is benefiting from the program through motivation, academic growth, behavior and attending and participating in schedule activities, workshops and events.

*Student may be dismissed due to breaking rules that have been outlined as automatic dismissal, items not limited to but including (drugs, stealing, bullying, sexual activity, threatening staff or students.)
Your child’s involvement will include many field trips, overnight excursions, summer end of the year trip assuming they are passing classes and not in disciplinary trouble.

I am confident that Upward Bound will have a lasting impact on our child’s life. Your student can still be in Upward Bound and not participate in the trips. They would receive knowledge and experiences with our workshops and tutoring programs. If you have any other questions about our program, please feel free to contact the Upward Bound office at (270) 809-2059.

Sincerely,

Trio Upward Bound Staff

PART A: Personal & Academic Information:
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Current Grade Level:blanks*
Current Cumulative GPA (4.0 Scale)blank*
Ageblanks* Sex (M or F) blank*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent - Cell phone*
Please enter a valid phone number.
Student - Cell Phone*
Please enter a valid phone number.
Parent - Email Address*
example@example.com
Student - School Email Address*
example@example.com
How does students name appear on Social Security Card? blanks*
Physical Handicap/ Learning Disability? blanks* If yes please explain the nature of the disability: blank*

U.S. Citizen or permanent resident:*
Are you in the United States for other than a temporary purpose and provides evidence from the Immigration and Naturalization Service of his or her intent to become a permanent resident:*
Are you a permanent resident of Guam, the Northern Mariana Islands, or the Trust Territory of the Pacific Islands:*
Are you a resident of the Freely Associated States - the Federated States of Micronesia, the Republic of the Marshall Islands, or the Republic of Palau*
Ethnic Origin:*
Do you plan to attend college?*
If yes, what area of study do you anticipate majoring in when you enter college? *
If not, what are your plans after high school?*

EMERGENCY INFORMATION:

Give the name, address and phone number of two adults (relatives or friends) who do not live with you, but can be contacted in the event of an emergency. A TELEPHONE NUMBER IS MANDATORY!
1. Emergency Contact Name One:*

First NameLast Name
Relationship to student:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number*
Please enter a valid phone number.
Work Phone Number*
Please enter a valid phone number.
2. Emergency Contact Name Two:*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home (Cell) Phone Number:*
Please enter a valid phone number.
Work Phone Number:*
Please enter a valid phone number.

PART B: Academic & Career Interests:

Please answer the following questions:
1. Why do you want to participate in the Murray State University Upward Bound Program? How will the program benefit you?*
2. What are your favorite subjects in school? What are your least favorite subjects? Please explain your choices.*
3. List organizations, community service activities, awards, and honors:*
4. What is your career goal?*

PART C: Parent’s Statement

Parents Statement: (To be completed by parents or guardians you live with).

The following information is provided in order to establish my child’s eligibility to participate in an Upward Bound Program. I understand the information concerning my child and me will be kept confidential and will not be revealed to anyone except Upward Bound personnel in accordance with the Family Educational Rights and Privacy Act.
Applicant's Name*

First NameLast Name
Guardian #1:*

First NameLast Name
Indicate relationship: *
Did you receive a 4-year college degree?*
Guardian #2:*

First NameLast Name
Indicate relationship: *
Did you receive a 4-year college degree?*
Family Size (Number of people in the household*
Did the family file a federal income tax report last year? If YES, complete Section A. If NO, complete Section B. *
Section A

Complete this if family filed a federal income tax report last year
Taxable Income (Select the range taxable income fall within)
Section B

Complete this only if family DID NOT file a Federal Income Tax Report last year.
Please select source(s) of income
You can select more than one
Total amount from all income source last year
Please enter dollar amount
Signature of Parent Guardian:*

Clear
Date*

MonthDayYear
Date

PART D: Student Information Release Forms

The information you provide to Upward Bound Program and/or Murray State University is for Upward Bound Murray State University, and the U.S. Department of Education use only. The information provided in this application is necessary to determine eligibility for the program and may be used for research purposes. Only Upward Bound, Murray State University personnel, and U.S. Department of Education personnel have access to these records.

PARENT/GUARDIAN PLEASE INITIAL EACH AREA OF CONSENT:
blanks* I give consent to release the following information to Upward Bound /Murray State University program as requested:

Standardized Test Results (ACT, SAT, CTBS, PSAT, etc.)
High School Grade Reports
High School Transcripts
College Admission and Financial and Aid Records
College Grade Reports and Transcripts
blanks* I give consent for Upward Bound /Murray State University staff and my child’s school representatives to discuss my child’s academic progress and general school activities for the purposes of identifying needs, coordinating services, and documenting my child’s overall scholastic progress. I and my child, fully understand that Upward Bound will track my child’s academic progress and admission status until he/she is no longer attending an institution of higher learning.
blanks* I give consent for Upward Bound/Murray State University to use photographs of my child for news releases, publicity, and other information about the program released to the public.
blanks* I give consent for this release to remain in effect until my child’s completion of college and/or post-graduate work is completed, if selected as an Upward Bound Program participant. If not selected for the Program, I give consent for the information provided in this application and information released as described above to be used by Upward Bound for research projects.
Student's Name*

First NameLast Name
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date

Permission & Medical Release Form
I/we hereby give my/our consent for blanks* to attend Upward Bound sponsored activities at Murray State University. I also have checked/or not checked the movie categories I allow for my child to watch. ____Rated G, __ Rated PG and ___Rated R. I have checked the box(s) of the movies I approve to watch. I also acknowledge the Upward Bound activities may include field trips, cultural events, and workshops. I understand that my child can/will be transported by all means of transportation. These means will be car, van, bus (school and charter), plane and train. I /we understand my/our child will be provided transportation to and from these events and hereby agree to same. As parent (s) or the natural guardian (s) of the above named student, I/we release Murray State University, its Board of Regents and individual Regents, directors, officers, agents, and employees, the Director of Upward Bound and any staff member of Upward (hereinafter referred to as “released parties”) from any and all liability for injury to the above named child, including death, which may arise from any causal factor, including negligence. In the event my/our under-age child should subsequently bring legal action and obtain judgment against the released parties, or any of them, I/we hereby bind and obligate myself/ourselves to indemnify said released parties up to and including the full amount of the judgement.
Date*

MonthDayYear
Date
Parent/ Guardian*

First NameLast Name
Home Phone Number*
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Signature*

Clear

Permission & Medical Release Form

This form will serve as the ONLY waiver valid for ALL Upward Bound (UB) Program activities

Because your son/daughter is below the legal age of consent (18 yrs.), the law requires that we have parent permission to obtain medical service should the need arise. Your signature on this consent form will authorize us to provide medication should the need occur. In the event of any major health problems, we will notify you as promptly as possible and follow your instructions.

UB STAFF IS NOT ALLOWED TO ADMINISTER PRESCRIBED MEDICATION AT ANY TIME.
Student Name*

First NameLast Name
Parent and Emergency Contact Information:
Parent/Guardian *

First NameLast Name
Phone Number*
Please enter a valid phone number.
Parent/Guardian Two*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Emergency Contact (other than parents)*

First NameLast Name
Emergency Contact (other than parents) Phone Number*
Please enter a valid phone number.

As parent or guardian, I authorize Upward Bound personnel to obtain needed emergency care as listed below:
Medical Insurance: blanks* Policy #: blank*
Medicaid/Medicare #: blanks* Policy #: blank*
Medical Doctor: blanks* Phone Number*
Preferred Hospital: blanks*
Student’s Date of Birth:*

MonthDayYear
Date
Blood Type (if known):
Current Immunizations Up to Date?*

YesNo
List any medications your child will be taking daily:*
List major medical conditions/allergies, behavioral issues, recent injuries, sight or hearing impairments and/or any limits on his/her physical activity (if any): *
Please select all the over-the-counter medications we are allowed to provide to your student
You can select more than one
Please list all over-the-counter medications or other allergens (i.e. seafood, peanuts) your child is allergic to:*
Students Name*

First NameLast Name
Signature*

Clear
Parent or Legal Guardian's Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

2024-2025

Murray State University TRiO Upward Bound Program

Section A

Section B