*Application should only be completed by parent(s)/guardian(s)

Dear Applicant:

Thank you for your interest in the Jackson State University Navigators Upward Bound Program. Upward Bound is a free college preparatory program for high school students funded by the U.S. Department of Education and sponsored locally by Jackson State University. Upward Bound is designed to provide participants the skills and motivation necessary to navigate and complete a program of secondary education and to enter and succeed in a program of post-secondary education.

Upward Bound is a year-round program. The program provides tutorial services, classes, and special events during the school year to strengthen academic skills and prepare students for success at the college level. The program also provides academic advising and individual assistance with the college admissions and financial aid application process during the academic school year. Our six-week summer academic component is designed to simulate a college-going experience that includes daily coursework in math, laboratory science, composition, literature, foreign language as well as cultural, social, and recreational events and activities.

Eligibility to participate in the program is determined individually. Each applicant must meet basic eligibility requirements set forth by the Department of Education, that require neither parent to have a four-year college degree and family income verification. Our program serves 60 students from Callaway and Murrah High Schools. Therefore, it is important that you complete your application as soon as possible. When space is not available, an applicant will be placed on our waitlist for later consideration.

All completed applications will be reviewed and eligible applicants contacted for a student and parent interview with program staff. Thank you for your interest in the Navigators Upward Bound Program. Please call a staff member at (601) 979-0327 if you have any questions or need assistance.

Sincerely,

Corinthia Bradfield, Director

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NAVIGATORS UPWARD BOUND PROGRAM

STUDENT APPLICATION

Demographic Information:

Last Name *

First Name *

Middle Name

Permanent Address *

Permanent City *

Permanent State *

Permanent Zip *

Social Security Number *

DOB *

Age *

Gender *

Citizenship *

Alien Registration Number

Please select languages spoken at home. *

Ethnicity *

Permanent Phone *

Cell Phone Number *

Email *

Disconnected Youth *

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Educational Data:

School ID Number *

Entry Grade Level *

Entry School *

Upon graduation form high school, what are your plans? Please select one *

Did you achieve proficient level on the Reading/Language Arts State Assessment? *

Entry GPA *

Expected Graduation Date *

Did you achieve proficient level on the Math State Assessment? *

Have you successfully completed Pre-Algebra or Algebra? *

Do you participate in extra-curricular activities? *

If yes, please list extra-curricular activities.

Are there any circumstances/disabilities that may affect the applicant's academic progress? *

If yes, please explain.

Are you presently enrolled in one of the TRIO Programs listed? *

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Academic Need Assessment:

Please respond to each statement below by selecting yes or no.

Tutoring *

Assistance with getting better grades *

Assistance in learning how to take better notes *

Assistance in choosing classes that will prepare me for college *

Assistance in applying for financial aid/scholarships/grants *

ACT/SAT/Subject Area Test Prep *

Improving self-esteem and social skills *

Assistance in choosing a career/college major that is best for me *

Assistance in knowing how to prepare for a career that interests me *

Assistance in test-taking strategies and techniques *

Assistance in developing or improving m time management skills/habits *

Improving my study skills and habits *

Assistance in applying for college admission *

Opportunities to visit colleges *

Experience more cultural activities *

Receive information on college prep courses and dual enrollment *

Receive information about college programs and degrees *

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Applicant Essays:

Both essays must be completed by the applicant with a minimum of five sentences.

1. Please explain why you want to participate in the Jackson State University Navigators Upward Bound Program.

Essay *

2. Upward Bound is committed to helping students enroll in college ad complete a degree to become successful in a career of their choice. What is your intended major or career? Why?

Essay *

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First Generation Eligibility Verification:

Father/Male Guardian Name *

Is he living? *

Mailing Address *

Father/Male Guardian Educational Level *

Father/Male Guardian Place of Employment *

Father/Male Guardian Cell Phone Number

Father/Male Guardian Home Phone Number

Father/Male Guardian Email Address

Mother/Female Guardian Name *

Is she living? *

Mailing Address *

Mother/Female Guardian Educational Level *

Mother/Female Guardian Place of Employment *

Mother/Female Guardian Cell Phone Number

Mother/Female Guardian Home Phone Number

Mother/Female Guardian Email Address

First-Generation Certification Statement-By completing this form, which will serve as a statement of educational attainment, you are certifying that the information submitted regarding parent/guardian educational attainment is true to the best of your knowledge.

Parent/Guardian Signature *

Signature Type: Simple Start Over

Signature: (Type in your full name)

I agree to the terms included.

Date *

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Income Verification Information:

How many people live in your household? *

Source of Income: Please select the primary source of income. *

Household Income Range *

Income Certification Statement: By completing this form, which will serve as a statement of income, you are certifying that the information submitted regarding the family size and taxable income is true to the best of your knowledge.

Parent/Guardian Signature *

Signature Type: Simple Start Over

Signature: (Type in your full name)

I agree to the terms included.

Parent/Guardian Date *

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School Records Release:

I understand that as part of the Jackson State University Navigators Upward Bound Program selection process, my child’s school records including transcripts, test scores, and academic progress reports may need to be examined.

I also understand that if my child is selected for the Jackson State University Navigators Upward Bound Program, the Upward Bound Program will continue to require this information from my high school and college. This information is necessary to track the performance of the Program’s participants and graduates.

I hereby give permission for Jackson State University Navigators Upward Bound Program to request the following information from my child’s high school and future colleges that he/she may attend:

Transcripts
Progress reports
Standardized test scores
Attendance records
Disciplinary Actions
Evaluations
Medical records

Student's Signature *

Signature Type: Simple Start Over

Signature: (Type in your full name)

I agree to the terms included.

Student's Date *

Parent/Guardian Signature *

Signature Type: Simple Start Over

Signature: (Type in your full name)

I agree to the terms included.

Parent/Guardian Date *

The Family Educational Rights and Privacy Act (FERPA), 20 U.S.C. §1232g, are respectively federal and state laws providing for the review and disclosure of student educational records. JSU Navigators Upward Bound Program will not permit access to or the release of personally identifiable information contained in the student educational records to any party without the written consent of the student, except as authorized by FERPA.

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Certification of Application and Information Release:

I/We certify that the information provided on the application is true and correct to the best of my/our knowledge; I/We further understand that the completion of this application does not guarantee acceptance into the JSU Navigators Upward Bound program.

I/We authorize the use of my image and name in JSU Navigators Upward Bound publications, editorials, advertisements, and media releases to the program and its affiliated organizations.

My/Our consent will remain in effect until I/We revoke this authorization, in writing, with the JSU Navigators Upward Bound office.

Student's Signature *

Signature Type: Simple Start Over

Signature: (Type in your full name)

I agree to the terms included.

Student's Date *

Parent/Guardian Signature *

Please select a signature verification type.

Parent/Guardian Date *