Upward Bound Registration Packet

Upward Bound Program Student Application for Admission

UPWARD BOUND PROGRAM Upward Bound is federally funded through the US Department of Education

Step 1 of 7

Section 2 - Income Verification
INCOME VERIFICATION
The following information is required by the federal government for income verification and should be accurate and exact. Your answers will be held in strict confidence. If you have questions, please call 803-705-4942. Please list all people living in your house including you: (If additional space is needed, please attach a separate sheet, which lists the names of household members and all other information requested.)
*
NAME Age RELATIONSHIP TO APPLICANT HIGHEST GRADE COMPLETED
Check the applicant’s lunch status that applies:*
- Free
- Reduced
- Pay
Additionally, please complete the financial statement verifying your income
I,*
attest that my annual or taxable income is $*
I also, understand that additional documents can be requested to verify income, if necessary. I certify with my signature below that the information regarding my income is accurate to the best of my knowledge.
Parent’s Signature*
Date*
MM slash DD slash YYYY
PRIVACY ACT AND CONFIDENTIALITY STATEMENT

The personal information you give to the Upward Bound staff is compiled and reported to the United States Department of Education. The information is protected by the Family Educational Rights and Privacy Act of 1974. No one may see the information unless they work with or for the Upward Bound Project or are specifically authorized to see the information. The information is necessary to help determine if your child is eligible to participate in the program in which the goal is to assist students in obtaining a post-secondary education. The Department of Education has the authority to gather information to help make Upward Bound a better program for future participants. (20 United States Code 12 3/A)

Great care is taken to make sure that the personal information collected on students is kept confidential. Any student who wishes to be considered for membership in the Benedict College Upward Bound Program and receive its benefits must agree to submit all necessary information requested by Project personnel.

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Section 7 - Authorization for Release of Academic Records
Name*
First Middle Last
Social Security Number*
The Benedict College Upward Bound Program is required to obtain information from other sources to meet your academic needs and for annual reporting requirements of the U.S. Department of Education. The US Department of Education requires verification of each participant’s academic performance (Grade Point Average –GPA); standardized test scores; secondary school retention and graduation; completion of rigorous secondary school program of study; postsecondary enrollment; and postsecondary completion. We may need to gather information from middle schools, high schools, colleges, universities, a College Entrance Examination Board and other agencies. In accordance with the Family Educational Rights and Privacy Act (FERPA) and Federal Law PL-93-380, section 348, the Benedict College Upward Bound Program must have written permission from the parent or eligible student (students 18 years or older). Your signature on this form authorizes UB to: • Request a copy of your school and/or college transcript and test scores • Request a copy of school schedules and activities • Request a copy of your SAT and/or ACT test scores • Use your social security number to request a copy of your financial aid application, transcripts, and college enrollment status, and awards from federal & state funding agencies, post-secondary institutions, and the National Student Clearinghouse. • Communicate with representatives from agencies, high school or postsecondary institutions on your behalf. This authorization for release of academic records form serves as the only form valid from the date signed until completion of the student’s postsecondary degree, which allows the Benedict College Upward Bound Program to gather data as needed for federally mandated reporting.
Signature of Student*
Date*
MM slash DD slash YYYY
Signature of Parent/Guardian*
Date*
MM slash DD slash YYYY

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Upward Bound Registration Packet

Upward Bound Program Student Application for Admission

Step 1 of 7

Section 1 - Student General Information

Section 2 - Income Verification

PRIVACY ACT AND CONFIDENTIALITY STATEMENT

Section 3 - Parents'/Guardians' Education Status:

Section 4 - Medical Information

Section 5 - Guidance Counselor Recommendation

Download Guidance Counselor Recommendation

Section 6 - Parent/Guardian Consent Form for use of Online Platform

Section 7 - Authorization for Release of Academic Records

NAME	Age	RELATIONSHIP TO APPLICANT	HIGHEST GRADE COMPLETED