Upward Bound Application Student Information Student Name Age Date of Birth LPS Student ID Number High School Name Citizenship - United States Other 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 2020-2021 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 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 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 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 Submit
