Upward Bound - Johnson

New Participant Application
Student Information:
First Name *
Middle Name
Last Name *
Preferred Name
Date of Birth *
Gender *
Race *
Hispanic or Latino?
What is your citizenship status *
Mailing Address *
City *
State *
Zip *
Student Phone Number *
School Email Address *
Preferred mode of contact *

Academic Information:
Current High School *
Current Grade Level *
Current School Counselor *
Are you currently part of GEAR UP or Talent Search? *

 

As a part of your application, we require a recommendation from a Math, Science, or English teacher. Please indicate below who you would like this to come from.
Recommender Name *
Recommender Email *

Family Information:

You will need a parent/guardian to help you complete this section.
Parent/Guardian #1 Name *
Parent/Guardian #1 Address *
Parent/Guardian #1 City *
Parent/Guardian #1 State *
Parent/Guardian #1 Zip Code *
Parent/Guardian #1 Phone Number *
Contact 1 Email Address *
Parent/Guardian #1 Employer *
Parent/Guardian #1 Relationship *
Did parent/guardian #1 graduate with a four-year degree from a college or university? *
If yes, which college or university?
Parent/Guardian #2 Name
Parent/Guardian #2 Address
Parent/Guardian #2 City
Parent/Guardian #2 State
Parent/Guardian #2 Zip Code
Parent/Guardian #2 Phone Number
Parent/Guardian #2 Email Address
Parent/Guardian #2 Employer
Parent/Guardian #2 Relationship
Did parent/guardian #2 graduate with a four-year degree from a college or university?
If yes, which college or university?

Household Financial Information:

You will need federal tax information (2024 IRS 1040) to complete this section.

Upward Bound is funded through the U.S. Department of Education to serve first-generation and modest-income students from our target schools who want to attend college. We base income eligibility on the applicant's "Taxable" family income. Therefore, we are required to collect a copy of your most recent income tax return or if you did not file a tax return, information on other sources of income.

You may upload a copy of your most recent tax return here or it can be mailed to Upward Bound, VTSU-Johnson, 337 College Hill Road, Johnson, VT 05656 OR dropped off at school with the school counselor or in school coordinator.

We understand that this is sensitive information. If you have questions about the requirement, please reach out to the Upward Bound Director, Mareesa Miles (mareesa.miles@vermontstate.edu).
Which of these choices apply to you or your household? *
Currently Living With *
Number of people in household including the applicant/student *
What was your household Taxable Income (line 15 on 2024 Federal Tax Return 1040) *
2024 Federal Tax Return 1040
Statement of Accuracy:

By signing below, I certify that to the best of my knowledge, the information given in this application is correct.  I understand that misrepresentation of facts on this application will be cause for refusal of admission, cancellation of admission, or suspension from Upward Bound.
Student Signature
Signature Type: SMS    Start Over
After validation, the cell phone number will become part of the electronic signature.
Cell Phone Number:

Parent/Guardian Signature
Signature Type: SMS    Start Over
After validation, the cell phone number will become part of the electronic signature.
Cell Phone Number:

Authorization for Release of Information:

By signing below, I authorize Vermont State University Upward Bound to access and/or receive copies of my student's academic transcripts, progress reports, state proficiency scores, PSAT, SAT, ACT scores, attendance records and other information needed for application review, and if accepted, for the duration of their secondary and post-secondary education.  I also grant the Upward Bound staff permission to speak with teachers, counselors and other school administrators at my child's school in order to obtain and exchange information as part of the services provided by the Upward Bound program.

I understand the United States Department of Education requires the Vermont State University- Johnson Upward Bound program to report on my academic progress for six years following my graduation from high school. In addition, I understand that this information will be handled with strict confidence by Johnson Upward Bound staff according to federal regulations and that I may revoke this authorization in writing at any time.
Parent/Guardian Signature
Signature Type: SMS    Start Over
After validation, the cell phone number will become part of the electronic signature.
Cell Phone Number: