Application

Aplicacíon en Español

Legal First Name *

Middle Name

Legal Last Name *

Preferred Name

Date of Birth *

Gender on Current ID *

Gender the student identifies as?

For diversity purposes, what is the student's race? Please select 1 or more that apply by pressing CTRL on keyboard *

Are you Hispanic? *

What is your USA citizenship status? *

Is the student a Ward of the State? (under court-ordered guardianship, foster care, etc) *

Student Address *

Zip Code *

Student Cell Phone *

Student School Email *

Student Personal Email *

School *

Student ID *

Current Grade Level? *

Annual Household Income Previous Tax Year *

Family Size *

Parent/Guardian #1 (Primary Residence) First and Last Name *

Parent/Guardian #1 Relationship to Student *

Parent/Guardian #1 Cell Phone *

Parent/Guardian #1 Email *

Parent/Guardian #2 First and Last Name

Parent/Guardian #2 Relationship to Student

Parent/Guardian #2 Cell Phone

Parent/Guardian #2 Email

Emergency Contact #1 First and Last Name *

Emergency Contact #1 Cell Phone Number *

Emergency Contact #2 First Name and Last Name

Emergency Contact #2 Cell Phone Number

Parent/Guardian #1 Highest Level of Education? *

Parent/Guardian #2 Highest Level of Education? *

What is the highest level of education the student plans to complete? *

What type(s) of career(s) is the student interested in? *

Is the student in another college prep program? (i.e. ECA, Pottawatomie Promise, Talent Search.) Please select all that apply by pressing CTRL, if none select N/A. *

If yes, please select which program(s) *

FOR STUDENT: Why do you want to join the Upward Bound Program? *

FOR STUDENT: Which colleges interest you right now and why? *

FOR STUDENT: List any extracurricular activities both in and outside of school and your level of involvement. *

FOR STUDENT: List any volunteer or community service activities you participate in and what you do for each. *

FOR STUDENT: If you have a job, list where you are employed, average number of hours you work a week, and schedule. *

Reference #1 (Coach, Teacher School Staff) First and Last Name *

Reference #1 (Coach, Teacher, School Staff) Email Address *

Reference #2 (Coach, Teacher School Staff) First and Last Name *

Reference #2 (Coach, Teacher School Staff) Email Address *

All information provided will be kept in strict confidence in accordance with the Family Educational Rights & Privacy Act (FERPA), following standards set by FERPA and the participating school. I certify all information provided to be accurate to the best of my knowledge. I give permission for the release of information for Federal Grant reporting such as grades, attendance, test scores, and Post-Secondary enrollment verification to the AIM Institute and AIM’s Educational Programs Staff.
I also give my expressed written permission for any pictures/videos taken in connection with the activities of the corresponding AIM Educational Program, to be used in publications (newsletters, television, websites, presentations, magazines, articles, etc.)

PARENT/GUARDIAN: Please sign the application below.

By selecting 'I Agree' and submitting this form, I certify that the above information is correct to the best of my knowledge. I understand that this information is being provided as a matter of record; it will be kept strictly confidential. I authorize this program to obtain copies of my transcripts, test scores, financial aid awards, and other materials necessary for participation in the program. I will also grant permission for my photograph, photographic image, and/or video recorded image to be published in materials such as newsletters, annual reports, recruiting presentations, web pages, e-Profiles, etc., and release this program from any liabilities.

I Agree