PARTICIPANT APPLICATION Upward Bound University of South Alabama

Upward Bound
University of South Alabama
320 Alumni Circle, FCW-5
Mobile, Alabama 36688
(251) 460-7322
Note: Upward Bound is a federally funded program by the US Department of Education; in order to
determine your eligibility to participate in the program we are required to secure certain information.
All information will be kept strictly confidential. Please complete this application as accurately as
Part A: To be completed and signed by the Student Applicant
Name: __________________________________________________ SSN: _______ - _________ - _______
Home Phone: (
) __________________________________Cell Phone: (
) ______________________
E-mail Address___________________________________________________________________________
Mailing Address: _________________________________________________________________________
City: ______________________
State: _______
Date of Birth: _____/_____/____
Zip Code: __________
Name of School: __________________________________ Grade ______________________
Ethnicity: (Check one
African American/Black
Please answer each of the following questions:
Are you a U.S. Citizen?
Have you ever considered dropping out of school?
Do you have a desire to continue your education after high school?
Do you know the procedure to enroll in a college or vocational school?
Do you have information about obtaining money for college?
Are you currently participating or have you in the past participated in any other college prep program
(Educational Talent Search)?
Yes No
Student Signature____________________________________ Date_______________
Continue on Back
Part B: To be completed and signed by the Parent/Guardian
Parent Education & Income Information
Parent/Guardian Name ____________________________________________________________________
Address (if different from Applicant) __________________________________City______________________
State __________Zip ____________ Phone (H) ______________ (C) ______________ (W)______________
Parent/ Guardian Marital Status:
Married__________ Divorced __________ Single __________ Separated __________ Widowed __________
Did either Parent/guardian graduate from a 4 Year College? __________Yes __________No
Size of family (number in household, including self) _____________ Number of children under 18 __________
Please indicate tax return filing status:
Please attach a copy of your last year’s income tax form (1040) or proof of untaxed income
(AFDC, Social Security, and etc.)
Please check your family’s yearly TAXABLE income (Check One):
- $17,655
36,376 - $42,615
17,656 - $23,895
42,616 - $48,855
23,896 – 30,135
48,856 - $55,095
30,136 - $36,375
55,096 - $61,335
Certification and Signatures
We authorize the release of a copy of the ACT and SAT scores, school transcripts, financial records, any
other academic information, and test results needed for the Upward Bound Program to complete the
application process.
We understand that completion of this application does not guarantee acceptance into the Upward Bound
We certify that the information provided on this application is true and correct. We understand it will be held
in confidence by the Upward Bound staff.
Parent/Guardian’s Signature_______________________________________ Date_____________________
The University of South Alabama provides equal educational opportunities to and is open and accessible to all qualified students without regard to
race, color, creed, national origin, sex or qualified handicap/disability, with respect to all of its programs and activities.
Office Use Only: Coordinator Initials: _____________________ Date Evaluated: ____________
Revised 08/06/15
LI (Only) __________
FG (Only) __________ Other_____________