

Dear Applicant: Thank you for your interest in the Jackson State University Conquerors 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 instructional 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 application 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 Lanier, Jim Hill and Provine High Schools. Therefore, it is important that you complete your application as soon as possible. When space is not available, the applicant will be placed on our waitlist for later consideration. Please complete this application as thoroughly as possible. You cannot save and restart this application. You may want to review the included items, take some time to make notes and gather the required documents, and then return to submit your application. If you have any questions, please call our office at (601) 979-0223. 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 JSU Conquerors Upward Bound Program. Sincerely, India Johnson, Director
CONQUERORS UPWARD BOUND PROGRAM STUDENT APPLICATION
Demographic Information:
Student Last Name *
Student First Name *
Student Middle Name *
Permanent Address *
City *
State *
Zip *
Social Security Number *
Date of Birth *
Age *
Gender *
Alien Registration Number (if applicable)
Please select language spoken at home * English Spanish Both English and Spanish Other
Ethnicity * Black or African American White Hispanic Asian American Indian or Alaskan Native Native Hawaiian or Other Pacific Islander
Home Phone Number *
Cell Phone Number *
Email *
Disconnected Youth/At Risk Student- (Disconnected Youth is defined as an individual between the age of 14 and 24 who are homeless, in foster care, involved in the juvenile justice system, or neither employed nor enrolled in an educational institution.) * Homeless Foster Care Involved in the Juvenile System Not enrolled in school I am not a disconnected youth/at risk student

Educational Data:
Name of Current School *
School ID Number *
Current Grade Level *
Grade Point Average
Name of school attending next academic year?
Expected Graduation Date
Upon graduation from high school, what are your plans? * 4-year University/College Program 2-year College Program Technical/Vocational/Trade Program Military Become Employed Not Sure
Did you achieve proficient level on the Reading/Language Arts State Assessment? * Yes No N/A
Did you achieve proficient level on the Math State Assessment? * Yes No N/A
Have you successfully completed Pre-Algebra or Algebra? * Yes No N/A
Do you participate in extra-curricular activities? * Yes No
Are there any circumstances/disabilities that may affect the applicant's academic progress? * Yes No
If yes, please explain.
Are you presently enrolled in one of the TRIO Programs listed? * Hinds Community College Upward Bound or Upward Bound Math & Science Jackson State University Talent Search or Educational Opportunity Center Tougaloo College Upward Bound, Upward Bound Math & Science or Talent Search None
Do you have a relative or friend that is a member of a TRIO Program? * Yes No
If yes, please explain.

Academic Need Assessment:
Please respond to each statement by selecting yes or no
Tutoring * Yes No
Assistance with getting better grades * Yes No
Assistance in learning how to take better notes * Yes No
Assistance in choosing classes that will prepare me for college * Yes No
Assistance in applying for financial aid/scholarships/grants * Yes No
ACT/SAT/Subject Area Test Preparation * Yes No
Improving self-esteem and social skills * Yes No
Assistance in choosing a career/college major that's best for me * Yes No
Assistance in knowing how to prepare for a career that interest me * Yes No
Assistance in test-taking strategies and techniques * Yes No
Assistance in developing or improving my time management skills/habits * Yes No
Improving study skills and habits * Yes No
Assistance in applying for college admissions * Yes No
Opportunities to visit colleges * Yes No
Experience more cultural activities * Yes No
Receive information on college prep courses and dual enrollment * Yes No
Receive information about college programs and degrees * Yes No

Applicant Essay (Completed by Student): Both essays must be completed by the applicant with a minimum of five (5) sentences.
1. Please explain why you want to participate in the Jackson State University Conquerors Upward Bound Program?

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


First Generation Eligibility Verification (Completed by Parent/Guardian):
Mother's First and Last Name *
Living or Deceased? * Living Deceased
Mailing Address *
Mother's Highest Level of Education * K-12 High School Diploma GED Certificate Associate's Degree (2-year) Bachelor's Degree (4-year) Graduate Degree
Place of Employment *
Home Phone Number *
Cell Phone Number *
Email Address *
Father's First aned Last Name *
Living or Deceased? * Living Deceased
Mailing Address
Father's Highest Level of Education * K-12 High School Diploma GED Certificate Associate's Degree (2-year) Bachelor's Degree (4-year) Graduate Degree
Place of Employment
Home Phone Number
Cell Phone Number *
Email Address
Guardian's First and Last Name
Mailing Address
Guardian's Highest Level of Education K-12 High School Diploma GED Certificate Associate's Degree (2-year) Bachelor's Degree (4-year) Graduate Degree
Place of Employment
Home Phone Number
Cell Phone Number
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.

Income Verification Information (Completed by Parent/Guardian):
How many people are in your household? *
Source of Income * Employment Retirement Unemployment Benefits Disability Benefits Social Security Benefits SNAP/TANF Other
If other, please list
Household Income Range * $0-$22,590 $22,591-$30,660 $30,661-$38,730 $38,731-$46,800 $46,801-$54,870 $54,871-$62,940 $62,941-$71,010 $71,011-$79,080
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.

School Records Release Form (Completed by Parent/Guardian and Student):
I understand that as a part of the Jackson State University Conquerors Upward Bound Program selection process, my child's school records including transcripts, test scores, and academic progress reports will be examined. I also understand that if my child is selected for the Jackson State University Conquerors 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 participants and graduates. I hereby give permission for Jackson State University Conquerors Upward Bound Program to request the following information from my child's high school and future colleges that he/she may attend:
Student Name *
Student Signature * Signature Type: Simple Start Over Signature: (Type in your full name) I agree to the terms included.
Parent/Guardian Name *
Parent/Guardian Signature * Signature Type: Simple Start Over Signature: (Type in your full name) I agree to the terms included.
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 Survivors 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.

Certification of Application and Information Release (Completed by Parent/Guardian and Student):
I/We certify that the information provided on the application is true and correct to the best of my/our knowledge; I further understand that the completion of this application does not guarantee acceptance into the JSU Conquerors Upward Bound Program. I/We authorize the use of my/our image and name in JSU Conquerors Upward Bound publications, editorials, advertisements, and media release 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 Conquerors Upward Bound office.
Student Name *
Student Signature * Signature Type: Simple Start Over Signature: (Type in your full name) I agree to the terms included.
Parent/Guardian Name *
Parent/Guardian Signature * Please select a signature verification type.