Application

UPWARD BOUND

SALEM INTERNATIONAL UNIVERSITY

SALEM, WEST VIRGINIA 26426

(304) 782-5261

(877) 391-0029

Date:________

Name _____________________________________Nickname/Preference:___________

Last First Middle

Address_____________________________________________________Zip_____________

Telephone ___________________ Social Security Number___________________ Age_____

Place of Birth__________________________Date of Birth_________________________

City State Month Day Year

Are you a U.S. citizen?_________If no, state legal status:______________________________

High School_____________________________________________Grade________________

Do you live with foster parents?__________________________________________________

Do you plan to attend a college or university after graduation?________If no, why?_________

____________________________________________________________________________

HOUSEHOLD INFORMATION

Father's Name_________________________________________________ Age__________

(or step) Last First Middle

Occupation__________________________________________________________________

Employer___________________________________________________________________

Name Complete Address

Highest Grade Completed 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Name of College, if any________________________________Degree__________________

Mother's Name_________________________________________________ Age_________

(or step) Last First Middle

Occupation__________________________________________________________________

Employer___________________________________________________________________

Name Complete Address

Highest Grade Completed 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Name of College, if any_____________________________Degree____________________

ADDITIONAL PARENTAL INFORMATION (NOT LIVING IN YOUR HOME)

Father's Name_____________________________ Highest Grade Completed _________

Mother's Name____________________________ Highest Grade Completed _________

FAMILY INFORMATION

BELOW LIST ALL PERSONS LIVING IN YOUR HOUSEHOLD (NOT COUNTING YOURSELF) INCLUDING ALL CHILDREN AND OTHERS.

NAME OF SCHOOL OR COLLEGE

NAME OR OCCUPATION AGE GRADE

__________________________________________________________________________

FAMILY'S ANNUAL INCOME

IF APPLICANT HAS FOSTER PARENTS, DO NOT COMPLETE THIS SECTION.

IF YOU DID NOT FILE A 1040 PLEASE EXPLAIN WHY IN THE SPACE BELOW.

PLEASE PROVIDE TAXABLE INCOME (NOT ADJUSTED GROSS) IN THE SPACE BELOW FROM THE 1040 FORM ON WHICH THE STUDENT IS CLAIMED. IF YOU FILED THE 1040, LINE 40 ; IF YOU FILED THE 1040A, LINE 27; IF YOU FILED THE 1040EZ, LINE 6; IF YOU FILED THE TELEFILE, LINE K (1).

LAST TAX YEAR ESTIMATED THIS YEAR

FATHER OR GUARDIAN $_______________ $_______________

MOTHER OR GUARDIAN $_______________ $_______________

JOINT RETURN $_______________ $_______________

NUMBER OF DEDUCTIONS CLAIMED _____________

* * * * * * * * * * * * * * * * * * * * * * * *

CHECK THE APPROPRIATE SPACE IF ANYONE IN THE FAMILY RECEIVES ASSISTANCE FROM ANY OF THE FOLLOWING SOURCES. DO NOT INCLUDE AS INCOME ABOVE.

_____SOCIAL SECURITY $______________/MONTH

_____WORKER'S COMPENSATION $______________/MONTH

_____VETERAN'S ADMINISTRATION $______________/MONTH

_____AID TO DEPENDENT CHILDREN $______________/MONTH

EXPLANATION OR ADDITIONAL INFORMATION:_______________________________

________________________________________________________________________________________________________________

I CERTIFY THAT THE INFORMATION GIVEN IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND ELIGIBILITY FOR UPWARD BOUND IS BASED UPON THE RECEIPT AND ACCURACY OF THIS INFORMATION.

THIS MUST BE SIGNED ____________________

SIGNATURE OF PARENT OR GUARDIAN

AUTOBIOGRAPHY

Write an autobiography, but don't repeat information you already provided elsewhere in this application. Include something about your interests, your plans, and your ambitions. Especially comment on your goals concerning your education after high school. Please be comprehensive so that we have a good understanding of you. If additional space is needed, use the back of this paper.

RELEASE OF INFORMATION

DATE_______________________

PURSUANT TO THE FAMILY EDUCATIONAL RIGHTS AND PRIVACY ACT OF 1974, I HEREBY GIVE MY PERMISSION TO _____________________________ HIGH SCHOOL TO FURNISH THE UPWARD BOUND PROGRAM, SALEM INTERNATIONAL UNIVERSITY, SALEM, WV, 26426, ANY SCHOOL RECORDS AND INFORMATION CONCERNING MY CHILD, _____________________________, WHICH IS NEEDED FOR APPLICATION AND PARTICIPATION WHILE IN THE UPWARD BOUND PROGRAM.

SIGNATURE____________________________________

Student Applicant

SIGNATURE__________________________________RELATIONSHIP_________________

Parent or Guardian

ADDRESS_____________________________________

_____________________________________