UC Clermont Upward Bound Application (2024-2025)
Upward Bound is a FREE college preparedness program for high school students in grades 9-12. We focus on developing leadership skills, career exploration, self-esteem development, and pertinent college preparation such as understanding college jargon, finding financial aid, and preparation for the ACT/SAT tests. Our program is open to a maximum of 72 students per year who have at least a 2.00 GPA, show a strong commitment to participating in our program, and meet either income eligibility and/or First Generation status as determined by parental educational level.
BASIC INFORMATION
Student's Full / Legal Name
*
First Name
Last Name
Middle Initial
Social Security Number (needed to pay participation stipends):
Student Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Student's Cell Phone Number
-
Area Code
Phone Number
Student's E-mail
*
example@example.com
Student's Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Student's Gender
*
High School of the Student
*
Batavia HS
Bethel-Tate HS
CNE HS
Felicity-Franklin HS
Georgetown HS
Goshen HS
Western Brown HS
Williamsburg HS
Grade in School
*
Rising 9th/end 8th
9th grade/freshman
10th grade/sophomore
11th grade/junior
12th grade/senior
Student's Ethnicity
*
Hispanic/Latino
Native American/Alaskan Native
Native Hawaiian/Pacific Islander
Asian
African American
European American/White
Two or more of the above
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Next
Family information
This information is necessary to determine the students eligibility to participate in the UC Clermont Upward Bound program.
Who does this student live with?
*
Both parents
Mother
Father
Mother & step-parent
Father & step-parent
Legal Guardian
Other
Father's Full Name
First Name
Last Name
Father's Occupation
Mother's Full Name
First Name
Last Name
Mother's Occupation
Guardian's Full Name
First Name
Last Name
Guardian's Occupation
Is the student now in or has ever been in Foster Youth Care?
*
YES
NO
Does either parent or guardian have a completed 4-year (Bachelors) degree?
*
Yes
No
CONFIDENTIAL Information REQUIRED by the U.S. Department of Education.
Take the Taxable Income or Adjusted Gross Income from your most recent tax form. For 2020, use Line 15 on the Forms 1040 and 1040SR. If you are not required to file a tax return, choose $0. Taxable income is different from gross income or take-home pay. For example, for a family of four, taxable income is normally at least $18,000 per year LESS than gross income. We use this information to determine your child's eligibility for the program.
What is your family's TAXABLE income?
*
$0-$22,590 (Not required to file)
$22,591-$30, 660
$30,661-$38,730
$38,731-$46,800
$46,801-$54,870
$54,871-$62,940
$62,941-$71,010
$71,011 or higher
Number of family members in household:
*
The Student is... (citizenship status)
*
a US citizen/national
a US permanent resident
Seeking naturalization
None of above
Legal Guardian completing this application
We are asking for your name and a phone/email contact so that we can reach you quickly if we need to clarify any information on this form.
Guardian's Full Name
*
First Name
Last Name
Guardian's phone Number
-
Area Code
Phone Number
Guardian's E-mail
example@example.com
Certification and Release of Information
I certify that all of the information entered above is accurate to the best of my knowledge. I give permission for the UC Clermont Upward Bound Program to have access to any school records of the above named student to determine academic and/or income eligibility for the program and to monitor status and progress in secondary and postsecondary education.
Signature (Use computer mouse or touch screen to sign)
*
Submission Time
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Month
-
Day
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
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UC Clermont Upward Bound Release of Transcript & School Record Information
Student's Full / Legal Name
*
First Name
Last Name
Grade in School
*
Rising 9th/end 8th
9th grade/freshman
10th grade/sophomore
11th grade/junior
12th grade/senior
High School of the student
*
Batavia HS
Bethel-Tate HS
CNE HS
Felicity-Franklin HS
Georgetown HS
Goshen HS
Western Brown HS
Williamsburg HS
If your student currently attends a career center, please name that school here.
To the Staff of the schools named above:
Please allow Upward Bound personnel to have access to copies of grade reports, standardized test score results, pertinent education plan information, and transcripts for the above named student.
Student Signature (Use computer mouse or touch screen to sign)
*
Parent/guardian Signature (Use computer mouse or touch screen to sign)
*
Submission Time
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Month
-
Day
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
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Student Interest and Needs section
We ask that the student wishing to join the UC Clermont Upward Bound (UB) Program complete this section to the best of his/her ability.
How did you learn about UC Clermont Upward Bound? Check all that apply
I saw a video about UB
I saw a poster about UB
A teacher/school counselor recommended UB
A friend recommended UB
I saw a UB Staff presentation
Other
Please check all the areas for which you would like to receive information or help.
Academic Tutoring
Academic Advising
Cultural Activities
College Visits
Financial Aid Assistance
Preparing for ACT/SAT
Study Skills
Career Awareness
Assistance with College Admissions
Participation in Community Service Activities
What are your plans after High School?
I am undecided about my future plans after high school.
I have NO plan to continue education after high school.
I DO plan to continue my education past high school.
If you said you DO plan to continue your education, what are you considering? (check all that apply)
Attending a College/University after High school
Attending a Community College after high school
Attending a Business School
Attending a Technical School
Attending a Vocational School
Finding an Internship in a career
Enlisting in the military to pay for college
Joining a military ROTC program at college to pay for college while attending
What areas are you interested in pursuing beyond high school
Agriculture/Farming
Art/Architechure
Business
Communications
Education/Teaching
Engineering
Government
Humanities/History
Law
Medicine
Military
Music
Performing Arts
Science
Social Services
Other
Please list three goals or plans you hope to achieve in your future.
Student Signature
Submission Time
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Month
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Day
Year
Date
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6
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:
Hour
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Minutes
AM
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AM/PM Option
Submit
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