Upward Bound

Student Information

Student Name

Age

Date of Birth

LPS Student ID Number

High School Name

Citizenship

- United States Other

Social Security Number

Sex

- Male Female

Student Phone Number

Parent Phone Number

Race/Ethnic Group

- African American American Indian Asian Hispanic Caucasian Other

Student Email

Parent Email

Current Grade Point Average

Write a paragraph describing your educational and career goals and how you plan to achieve these goals.

If selected as a member of the Upward Bound program at Cameron University, I agree that I will participate in the entire program and conduct myself in a way to bring credit to my family, my community, school and the Upward Bound program. I will abide by the rules and regulations set forth in the Upward Bound policy for the entire length of time that I am a member. I agree that I will attend planned meetings and activities during the academic year and the summer program. For the 2018-2019 school year, the program received $352,981 to serve 66 students in Lawton Public Schools.

Student Signature (Please type your full name)

Date

Parent or guardian with whom the applicant lives

Parent or guardian 1 name

Parent or guardian 1 relationship to applicant

Parent or guardian 1 occupation

Parent or guardian 2 name

Parent or guardian 2 relationship to applicant

Parent or guardian 2 occupation

All Information will be held in strict confidence. Federal regulations require verification of family income as part of the application process for Upward Bound. Please see the family size and income eligibility list for Upward Bound in Oklahoma and check which box best matches for your family.

Size of Family Unit

- 1 2 3 4 5 6 7 8

Taxable Income (For households with more than 8 members, add $6,630 for each additional household member)

- Equal to or less than $18,735 Equal to or less than $25,365 Equal to or less than $31,995 Equal to or less than $44,430 Equal to or less than $52,050 Equal to or less than $59,670 Equal to or less than $67,290 Equal to or less than $74,910

Is either parent a graduate of a four year college or university with a Bachelor's degree?

- Yes No

Is English a second language for this student?

- Yes No

Please provide the full name of a teacher or counselor that you would like to use as a referral for admission into the Upward Bound program

Please provide the address of the teacher or counselor that you would like to use as a referral for admission into the Upward Bound program

Please provide the phone number of the teacher or counselor that you would like to use as a referral for admission into the Upward Bound program

This is to certify that all information given by me is true and correct to the best of my knowledge. Furthermore, I give Upward Bound my permission to receive copies of my child's educational records and other material necessary for participation in the program. Further permission is granted to request academic and financial aid information and records from any and all post-secondary institutions and tracking agencies (utilizing social security number and any personal identification information contained herein) in order to track college progress. I understand all of child's records will be kept in confidence in accordance with the Privacy Act of 1974. If selected as a member of the Upward Bound program at Cameron University, I agree that my child will participate in the entire program and conduct themselves in a way to bring credit to our family, our community, school and the Upward Bound policy for the entire length of time that my child is a member. I agree that my child will attend planned meetings and activities during the academic year and the summer program. I give Upward Bound permission to use and publish photographs and videos of my child for advertising and any other purpose the program would need it for.

Parent/guardian signature (Please type full name in the box)

Date