Applicant Name: ______________________________ High School: ____________________________
_____________________________________________________________________________________
STUDENT APPLICATION PACKET
Upward Bound is a FREE college preparatory program for first-generation and
income-qualified students from the select target high schools of Loris High School and
Carvers Bay High School. The program is federally funded through the U.S.
Department of Education. The services of the Upward Bound Programs assist students
in exploring college and career opportunities, preparing them to enter and succeed in
postsecondary education upon graduation from high school. During the academic
year, Upward Bound participants attend weekly tutoring sessions and mandatory
monthly College Preparatory Saturday Sessions where they are provided with
information about college, careers, study skills, financial aid, financial literacy, and
standardized test preparation, as well as participating in cultural/enrichment
activities. The program provides individual academic counseling and advising in target
high schools. Upward Bound participants also attend a six-week academic summer
program on the Horry Georgetown Technical College, Conway campus.
All Upward Bound services are FREE to participants.
For questions or additional information, please contact us at:
Upward Bound Programs
Horry Georgetown Technical College
PO Box 261966
2050 Hwy 501 East
Conway, SC 29528-6066
843.349.7843 Phone
843.349.7573 Fax
Dear Parent(s) or Guardian(s):
Your student is being invited to participate in a nation-wide college preparatory program. I cordially
invite you to read further and take advantage of this opportunity.
Upward Bound is a federally funded college access program designed to assist low-income and
potential first generation college students who are currently in high school to pursue post-secondary education
upon high school graduation. Students may only be accepted into the Program at the end of the 8th grade or
during their 9th or 10th grade years. Once in the Program, students remain a participant until high school
graduation, must maintain no less than a 2.3 grade point average and are expected to attend services. The
Director has the final word on whether any student is accepted or continues in the program.
Upward Bound provides Individualized Tutoring (IT) services; Classroom Instruction (CI) in Math,
Science, English and Foreign Language; Saturday Enrichment Academy (SEA) which offers motivational
presentations and workshop on a variety of topics such as college financial planning, career and personality
assessment, test taking and study skills, etc. Additionally, college and university tours, student leadership
conferences and cultural events are scheduled throughout the year.
During the summer, participants have the opportunity to take Upward Bound enrichment classes on
The Horry Georgetown Technical College campus for six weeks to prepare them for the next year of study
in high school. While the Summer Program’s focus is academic it involves a full range of social, cultural and
recreational activities.
All Upward Bound services are provided at very little expense to participants. If you would like to
be considered for the Program, submit the following items along with your completed application:
1. A copy of your last 1040(A) tax form. If a family member is receiving AFDC, copy of food stamp
benefits, Social Security benefits, Unemployment Compensation or Section 8 housing letter,
submit a letter of benefits;
2. Student letter of interest – a) Why he/she would like to join the Upward Bound Program; and
b) What does it mean or take to be successful in today’s society?
3. Your student’s Counselor Recommendation Form (enclosed)
4. A copy of the student’s social security card
5. Cafeteria release of information form signed by cafeteria representative
6. A copy of student’s most recent grade report; and
7. Your student’s standardized test scores (which can be obtained from your child’s school).
Sincerely,
Enc.
The Upward Bound Program
Horry Georgetown Technical College
Upward Bound Program
Application Information
When Filling Out Application:
• Be sure to supply all requested information accurately and completely.
• Be sure parent and student sign all signature lines.
• Be sure to fill out & sign the Confidential Financial Information page regardless of income source.
When Submitting Application:
• Be sure to attach copies of the following verification documentation:
_____Student letter of interest – addressing: 1) Why he/she would like to join the Upward Bound
Program; and, 2) What does it mean or take to be successful in today’s society?
_____Counselor Recommendation (form enclosed);
_____ copy of the student’s social security card
_____Student’s most recent grade report (unless in 9th grade);
_____Student’s standardized (achievement) test scores (which can be obtained from student’s
school records if applicable); and
_____Copy of parent(s) tax forms, copies of AFDC, Food Stamp benefits, Social Security benefits or
Unemployment Compensation benefits or page 7 and 8 of this application completed.
Return Completed Application to:
Upward Bound Program
Horry Georgetown Technical College
Upon receipt of the completed application and copies of the verification documentation,
your student will be scheduled for an interview with the Upward Bound Program. The
Director has the final word on whether any student is accepted or continues in the
program. If you have any questions, contact our office at 843.349.7843.
APPLICATION
Horry Georgetown Technical College
Upward Bound Program
PO Box 261966
2050 Hwy 501 East
Conway, SC 29528-6066
843.349.7843 Phone
843.349.7573 Fax
Please type or print in ink.
Date of Application______________________
A. STUDENTS PERSONAL INFORMATION
SOCIAL SECURITY NO: ______-_________-__________ (REQUIRED)
Name__________________________________
Facebook Profile Name_______________________________________
Address__________________________________________________________
City, State & Zip
Birth date______/_______/_________ Age_____ Home Phone (____) __________
Month
U.S. Citizen?
Day
Yes
Cell Phone (____) __________
Birth Year
No
Permanent Resident?
Yes
No
(Please provide a copy of your Green card)
Student Email address_____________________________ Parent Email address__________________________________
Sex:
Male
Female Student Cell No. (_____)___________________ Place of Birth __________________________
High School Attending_______________________________
Current Grade _________
Counselor_________________________________
Expected High School Grad Year ________________
Mother’s Name_____________________________________
Father’s Name_____________________________
Living?
Yes
No
Living?
Yes
At home?
Yes
No
At home?
Yes
No
No
Occupation__________________________________
Occupation________________________________
Work Phone (_____) __________________________
Work Phone (_____) ________________________
Mother’s Cell No. (_____) ______________________
Father’s Cell No. (_____)_____________________
Parents’ marital status:
Married, living together
Married, living separately
Single
Divorced
Legal Guardian, if different from above______________________________________________________________
Address_____________________________________________________ Phone No.(____)____________________
List other children, starting with the oldest:
Name
Gender Age
_________________________
_____ ____
_________________________
_____ ____
_________________________
_____ ____
_________________________
_____ ____
List other family/persons living in household:
Name
Gender Age
_________________________
_____ ____
_________________________
_____ ____
_________________________
_____ ____
_________________________
_____ ____
(attach additional page if necessary)
Ethnic Background?
Asian
African American
Living at home, college:
__________________________
__________________________
__________________________
__________________________
Grade Level
_______________________
_______________________
_______________________
_______________________
Relationship to student:
__________________________
__________________________
__________________________
__________________________
Grade Completed
_______________________
_______________________
_______________________
_______________________
Native American
Caucasian
Hispanic
Other _____________
Do you have any physical condition or disability, which requires special treatment or other considerations?
Yes
No If yes, please explain: _________________________________________________________________
Why do you want to join Upward Bound? Student must attach a letter of interest – please include
1) Why he/she would like to join the Upward Bound Program; and,
2) What does it mean or take to be successful in today’s society.
Is Custodial Parent/Guardian a High School Grad?
Mother
Does Custodial Parent/ Guardian have a Bachelor Degree?
Yes
Mother
No
Yes
Father
No
Yes
Father
No
Yes
No
(IfYes
YES,
please
No complete page 8 of this application)
Do you receive free/reduced lunch?
B. GRADUATION INFORMATION
Indicate the type of training/education that you are interested in after you complete high school:
 Vocational (Trade)
 Community College/Technical College
 Military
 Undecided
 4-Year College/University
What are your career interests? _______________________________________________________________________
C. GENERAL INFORMATION
How did you learn about Upward Bound? ______________________________________________________________
___________________________________________________________________________________________________
Do you need tutoring assistance?
Yes
No
If yes, what subject (s)? ____________________________________
List any extra-curricular activities/clubs/sports that you are currently involved in:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
List any community service or jobs that you are currently involved in: ___________________________________________
___________________________________________________________________________________________________
Your signature below indicates that you are interested in participating in the HGTC Upward Bound Program to include
Mandatory after school and Saturday Tutorials and Workshops. The information provided above is true to the best of your
knowledge.
_____________________________________________
_________________________
Student’s signature
App Rec’d
Date
DO NOT WRITE BELOW THIS LINE – FOR OFFICE USE ONLY
App Rev’d
Applicant
Entry Date
No. in Family:
Accepted
( ) Yes ( ) No
Annual Income
Date Notified:
If no, why?
Low Income:
1st Generation:
D. PARENT/GUARDIAN CONTACT INFORMATION
Upward Bound would like to keep parents/guardians informed of what we are doing
with our students as well as remind you of important dates of upcoming events or
important deadlines for various testing, scholarships, etc. We post all deadlines and
activity reminders on Facebook and Instagram constantly. How can we send you
important Upward Bound announcements and event dates as well as stay in contact
with you?
Contact 1:
Name: ______________________________Relationship to Student ________________
Address: _________________________________________________________________
Street
City
State
Zip
Home Phone: (______) ________________ Cell: (______)________________________
Email: _____________________________
Facebook Name: ____________________
Contact 2:
Name: ______________________________Relationship to Student ________________
Address: _________________________________________________________________
Street
City
State
Zip
Home Phone: (______) ________________ Cell: (______)________________________
Email: _____________________________
Facebook Name: ____________________
Contact 3:
Name: ______________________________Relationship to Student ________________
Address: _________________________________________________________________
Street
City
State
Zip
Home Phone: (______) ________________ Cell: (______)________________________
Email: _____________________________
Facebook Name: ____________________
Please note that this program is a voluntary program and the parent or student can elect to
withdraw the student from participation at any time. However, the student is expected to
participate in this program and lack of participation is grounds for withdrawal from the
program.
E. HIGH SCHOOL INFORMATION
Current year in school:
9
10
11
12
High School Name:_____________________________ Counselor Name:_______________________
Personal Needs:
Please list, in order, the careers or occupation you are most interested in:
1. ____________________ 2. _______________________ 3. _________________________
Please list, in order, the colleges, universities or technical schools you may be interested in
attending:
2. ____________________ 2. ________________________ 3. _______________________
Please check all the academic areas you need assistance with (you may check more than one):
 E n glish / L iteratu re
 F oreign L an gu age
Math em atics
Scien ce
Social Stu dies______________
 O th er (specify
______
Please check from the following list so that we may assess your needs along with your
strengths and weaknesses in order to develop an individualized plan for you.
_____ Study Skills
_____ Time management
_____ Career Development
_____ Test Taking skills
_____ ACT/SAT Preparation
_____ College Planning
_____ Scholarship Location
_____ Financial Aid Help
_____ Using the internet
_____ Tutoring LIST SUBJECT AREAS!
1. ______________________ Comments: ___________________________
2. ______________________
___________________________
3. ______________________
___________________________
I certify the above information is true and accurate to the best of my knowledge.
______________________________
______________________________
Student Signature
Date
Confidential Financial Information
Date________________
Student’s Name _________________________________
1. Taxable income for the year {Taxable income is your income AFTER deductions (not total wages).
This amount is found on Line 6 (1040EZ), Line 43 (1040’s) or line 27 (1040A’s)...$ ______________
2. Number of people in your household (including yourself): Adults ____ Children _____
3. Type of tax return filed last year: Single
Joint
Separate
Did not file
3. If your family was not large enough to require that you
file an income tax return, please indicate the approximate
amount of your family income ……………………………….…… $ _______________
The number of family members supported by this income ..….…….. ______________
4. Does your family live in federally subsidized housing (HUD, Section 8, income based housing.……
______________
5. Are any members of your family on state/federal welfare/
social security/unemployment compensation programs? …..………… ______________
If yes, you must submit a letter of your benefits.
6. In order for your son/daughter to qualify for Upward Bound, you must be able to show that you could not
afford to pay for such services yourself. Usually, this decision is based on your last year’s income, but in
special cases, it can be based on this year’s income. If you can show there has been a major change in your
family’s financial condition since last year, (i.e., one or more family members being out of work) explain
your situation in the following space or attach a letter of explanation.
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
___________________________________
Signature of Parent/Guardian(s)
•Statement of Confidentiality – "The personal information you give to the Director of Upward Bound may
be sent to the Department of Education. The Privacy Act protects the information. No one may see the
information unless he or she works with or for the Upward Bound Program, or is specifically authorized to see
the information. The information is necessary to determine if the applicant is eligible to participate in the
program and helps the federal government to measure your success. If you do not give this information to the
Upward Bound Program and the Department of Education, you cannot receive any benefits from the program."
SHARING INFORMATION WITH UPWARD BOUND
Dear School Lunch Program:
The information that I gave on my Free and Reduced Price School Meals Application may be shared
with the Upward Bound Program at Horry Georgetown Technical College personnel to determine if
my children may qualify.
 Yes! I DO want school officials to share information from my Free and Reduced Price School
Meals Application with the Upward Bound Program at Horry Georgetown Technical
College.
Child's Name: ________________________________________ Grade: ________________ School: ________________________
Child's Name: ________________________________________ Grade: ________________ School: ________________________
Child's Name: ________________________________________ Grade: ________________ School: ________________________
Child's Name: ________________________________________ Grade: ________________ School: ________________________
Signature of Parent/Guardian: ___________________________________________ Date: _____________________________
Printed Name: ______________________________________________________________________________
Address: _____________________________________________________________________________________
________________________________________________________________________________________________
Phone number: _______________________________________________________________
SCHOOL LUNCH PROGRAM
The children listed above receive:
 FREE Lunch
 REDUCED Lunch
For 20__ - 20__ school year
Name of school official (printed): ______________________________________ Title: _____________________________
Signature of school official: ____________________________________________ Date: _____________________________
Please make a copy! We can accept the original or the copy back. Thank you.
UPWARD BOUND COUNSELOR RECOMMENDATION LETTER
Student Name _____________________________________
Current Grade Level _______________________
Counselor Name (printed) _____________________________ Subject area ______________________________
Counselor Signature_________________________________
Date____________________________________
Please provide three reasons this student will benefit from Upward Bound.
______________________________________________________________________________________________
______________________________________________________________________________________________
_____________________________________________________________________________________
Please complete both sections 1 and 2 of this table. Students must have demonstrated academic (Section 2) need to be
considered for Upward Bound.
1- Please check the qualities which best describe the
2- Please check the academic, career, and personal needs
commitment, talent and current skills of this student:
of this student:
Participates regularly in class discussions and activities
GPA: _________ < 3.25 (low GPA)
Shows interest in learning and seeks academic
Low Achievement Test Scores
challenge
Low Educational Aspirations
Is punctual and completes assignments on time
Low grade point average and low educational
Capable of performing at higher personal and academic aspirations
level
Low grade point average and low achievement test
scores
Demonstrates leadership abilities
Is organized and uses time effectively
Low achievement test scores and low educational
Behaves in a responsible and relatively mature manner aspirations
Lack of opportunity, support and/or guidance to take
Is responsible, self-directed and can work
challenging college preparation courses
independently
Attendance indicates academic need
Desire to pursue education beyond high school
Lack of career goals and/or need for accurate
information on careers
Motivation for post-secondary education shows
academic need
Lack of confidence, self-esteem, and/or social skills
Interest in careers in Math and/or Science
Limited English proficiency
Diagnosed learning disability
Predominantly low-income community
Rural isolation
Other: _______________________________________
Please evaluate the student’s current overall performance by circling one rating for each category:
Attendance (include tardiness):
excellent
good
fair
poor
inconsistent
Classroom Attitude/Behavior:
excellent
good
fair
poor
inconsistent
Maturity Level:
excellent
good
fair
poor
inconsistent
Work Ethic:
excellent
good
fair
poor
inconsistent
Motivation:
excellent
good
fair
poor
inconsistent
Potential to Achieve College Readiness: excellent
good
fair
poor
inconsistent
Based on my experience with the applicant, my recommendation to Upward Bound is as follows:
( ) Highly Recommend ( ) Recommend ( ) Recommend w/Reservation ( ) Do Not Recommend
Note: If you select the categories Recommend w/ Reservation or Do Not Recommend please explain.
COMMENTS OR ADDITIONAL INFORMATION: (You may attach an extra sheet or write on the back if further comments are
applicable.)
______________________________________________________________________________________
______________________________________________________________________________________
Students Pursuing Excellence Through Education
What is Upward Bound?
The Upward Bound Program is an academic pre-college program funded by a grant from the U.S. Department
of Education. The purpose of the Upward Bound Program is to prepare and motivate low-income and/ or
first generation students to attend an institution of higher learning, and to be successful at the college or
university of their choice.
During the regular school year, students receive supportive services and weekly tutoring. Additionally, the
students attend Saturday Enrichment Academy (SEA) workshops. These workshops are interactive and focus
on math, science, English, foreign language, life & college skills. SEA provides academic, social & personal
growth that will enlighten students on college expectations and help them to be consistent in managing their
study skills.
What Services Are Provided?






Nine months of academic tutorial
service and academic enrichment
classes.
Five or six week Summer Program.
Assistance with the completion of
ACT, financial aid & college
applications.
Monthly Saturday workshops &
classroom instruction
College visitations in & out of state
Seniors are provided assistance locating
& applying for scholarships.
Students Who Are Eligible:

Rising 9th graders




9 & 10 grade high school students
Willing to take college prep classes.
Have obtained a 2.0 GPA.
Low income and/or
First-generation college bound.

th
th
What is the Cost of This Program?
There is virtually NO Cost to the student or their family for all of the services provided through the
academic year or the six-week summer program. Most fees for transportation to field trips, housing,
meals, classes and course materials are covered by the program.



Student Benefits
Group visits to a variety of colleges and universities.
Opportunities to travel out of state
Participation in various conferences, seminars and workshops in and out of state.


Improve grades, meet new friends and interact with students from other schools.
College credits earned during the Summer Transition Program may be transferred to participant’s
university of choice.
Who To Contact For Assistance:
Horry Georgetown Technical College
Upward Bound Program
PO Box 261966
2050 Hwy 501 East
Conway, SC 29528-6066
843.349.7843 ne
843.349.7573 Fax