Applications open September 29th SCHOLAR CONTACT INFORMATION Name Date Highschool/Grade Level Mailing Address School Name School Counselor Scholar Phone First Guardian Name Relation to scholar Phone Scholar Email GUARDIAN INFORMATION Guardian Email Second Guardian Name Second Guardian Relation to the Scholar Second Guardian Phone Second Guardian Email SCHOLAR INFORMATION Grade Point Average Date of Birth Are you of Hispanic/Latino Descent? Yes No Race (please check all that apply): American Indian Black/African Descent Asian/ Pacific Islander White Other (specify) Currently Live (please check one) With both parents With one parent: Mother Father Relative Foster Home × Status message Federal eligibility requirements for the Upward Bound Program require each applicant be a first generation college Scholar and/or low income. A first generation college Scholar is defined as a Scholar where neither parent has earned/received a bachelor’s degree from a college or university. Did either of your parents/guardians receive a Bachelor Degree? Yes No If so, who? AGREEMENT × Status message Do you understand that, if accepted, the GW-SMHS Upward Bound Program is an academic program that tracks your academic progress beyond high school and six (6) years into your college career? Please Select Yes No Unclear × Status message I hereby affirm that all financial & educational information listed in this application is true and correct. I understand any misrepresentation or false statement will make the applicant ineligible for the GW Upward Bound Program. parent_guardian_signature Reset Sign above Date × Status message If you did not file an income tax return and/or your income was not large enough to require that you file, please indicate the approximate amount of family income AND the number of household members supported by this income Family Income Amount & Household Amount × Status message CONFIDENTIALITY OF INFORMATION The financial and educational information you provide to the Upward Bound director is reported to the Department of Education and is protected by the Privacy Act. No one may see the information unless they work with or for the Upward Bound project or are specifically authorized by the Department of Education to evaluate the project. The Department of Education has authority to gather information to help make Upward Bound a better project (20 USC 1231a). Great care is taken to make sure that the personal information collected on Upward Bound students is kept confidential. Information or records relating to individual Upward Bound students or group(s) of students who are participating or have participated in Upward Bound projects shall not be disclosed to any person, group, agency, or organization without the express consent of the Director, Division of Student Services and Veterans Programs U.S. Department of Education. When a project or contract terminates, all Upward Bound records in possession of the project or contractor shall be disposed of only by the authority of and in accordance with procedures approved by the Director, Division of Student Services and Veterans Programs. In addition, any officer or employee of the United States or of any department or agency thereof who publishes, divulges, discloses or makes known in any manner or to any extent not authorized by law, any information coming to him in the course of his employment of official duties or by reason of any examination or investigation made by, or return, report or record made to or filed with such department or agency or officer thereof, which concerns or relates to the Upward Bound program shall be subject to a fine of not more than $1,000 or imprisoned not more than one year, or both, and shall be removed from office or employment under the provisions of Title 18, Section 1905 of the U.S. Code. × Status message I hereby affirm I am a citizen or permanent resident of the United States and all information contained in this application is true, to the best of my knowledge. signature_citizen Reset Name citizen_date I authorize the release of the following records to GWU SMHS Upward Bound from the present through post-secondary graduation. Authorization to release all of the following files Transcripts State Standardized Test Scores Financial Aid Information ACT/SAT Scores Post-secondary Enrollment Status Parent/Guardian Signature to authorize documents Reset Sign above Authorization Parent/Guardian Signature Date × Status message In accordance with the Privacy Act of 1974 (Public Law No. 93-579, 5 U.S.C. 552A), you are hereby notified that the Department of Education is authorized to collect information to implement the Upward Bound program under Title IV of the Higher Education Act of 1965, as amended (Pub. Law 102-325, sec. 402C). In accordance with this authority, the Department receives and maintains personal information on participants in the Upward Bound programs. The principle purpose for collecting this information is to administer the program, including tracking and evaluating participant’s academic progress. Providing the information on this form, including a social security number (SSN) is voluntary; failure to disclosure a SSN will not result in denial of any right, benefit or privilege to which the participant is entitled. The information that is collected on this form will be retained in the program files and may be released to other Department officials in the performance of official duties. Citizenship or Permanent Resident Affirmation Student Signature for Citizen or Permanent Residency Reset Sign above Student Name and Title for Citizenship or Permanent Residency Student Date for Citizenship or Permanent Residency Guardian Signature for Citizenship or Permanent Residency Reset Sign above Guardian Name and Title for Citizenship or Permanent Residency Guardian Date for Citizenship or Permanent Residency Submit Leave this field blank
