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Name *

First Middle Last

Address *

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone Number *

Email Address *

Date of Birth *

Gender *

Ethnicity *

How did you hear about the Veteran's Upward Bound Program? *

Are you a U.S. citizen? *

Yes
No

If not a U.S. citizen, please enter Alien Registration #

Employment *

Projected TAXABLE Net Income (not Gross) for the current calendar year. Do not include Disability Income, Alimony, Overseas Pay, Housing Allowance or Child Support *

Number in your Household (you and any dependents) *

Branch of Service *

Date of Discharge *

Do you have a current VA Disability Rating? *

Yes
No

Disability Rating

Type of Discharge *

High School Education *

High School Graduate
GED

Highest level of education *

Have you been out of school for 5 years or more? *

Yes
No

If no, are you currently in school?

Yes
No

Did your parent(s), natural or adoptive, graduate with a bachelors degree prior to you turning 18? *

Yes
No

Which Veterans Upward Bound services are you interested in? (check all that apply) *

Assessment of academic skills
Academic refresher courses
Development of an education/career plan
GED Completion
Assistance with Financial Aid and veterans’ benefits applications
Community/veterans’ agencies and supportive services referrals
Assessment of career interests
Assistance w/ post-secondary school applications
Information about college degree plans and programs

After completing the Veterans Upward Bound program, what are your educational plans? *

GED only (no school after VUB)
Community College/Vocational/Technical School
College/University

If you are planning on continuing your education what degree and/or course of study/program are you interested in?

Release of Information

I understand that by applying to participate in the VUB Program, I authorize VUB Program staff to obtain records of data pertinent to my VUB participation from other sources as identified and to release information to the United States Department of Education as mandated. The VUB Program staff also has my permission to communicate verbally or otherwise (email, cell phone, texting, etc) with myself, staff, faculty, and/or off-campus professionals on my behalf as identified below. I understand that all information will be kept confidential and that records will be used for documenting eligibility for the program and for reporting purposes. Unless written permission is given by you, the student, information maintained in your file will remain confidential and will not be released to a third party or agency. The only exception to this rule is in the clear instance of a legal duty to warn or report, or if your file is legally court ordered. Please discuss any questions concerning "legal duty" or "court ordered" with program staff prior to signing this form.

Release To/Request From

Admissions
High School/College/Military Transcript Requests
Testing Center (COMPASS, ACT, SAT Results)
Nation Student Clearinghouse - (Confirmation of post-secondary enrollment status. This authorization remains in effect for six years following enrollment in a post-secondary program.)
VA: Medical Center/Vet Success
First semester class schedule in post-secondary program. Enrollment in non-credit classes.

Photo Release Statement *

Do you consent to having your photo used for VUB program resources and materials? This may include use in marketing materials, websites, and/or social media.

Yes
No

Please upload a photo of yourself if possible

Max. file size: 10 MB.

Certification and Approval

I certify that the information provided in the application is accurate and complete. I agree VUB can use my image in their student database for identification purposes. I agree to use VUB computers for VUB activities only. Use of printer, copier, or fax equipment must be approved by VUB staff.

Signature of the Applicant (Type your name here) *

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Veteran’s Upward Bound Application

Release of Information

Certification and Approval

Veteran's Upward Bound