Keene State College Upward Bound Programs
 229 Main Street
Keene, New Hampshire 03435-1801
www.keene.edu/upward 

The KSC Upward Bound Programs are federally-funded college preparatory programs that prepare students for success in high school and enrollment in college. 

To be eligible for admission and participation, students must meet the following requirements:

  • be a U.S. Citizen or permanent resident;
  • be the first in their family to complete a 4-year college degree AND/OR come from a moderate income background (each as defined by the U.S. Department of Education);
  • demonstrate academic need; and
  • attend one of the programs’ target high schools.

Application process: 

  1. Submit Student Application Part 1: Student Information (to be completed by student)
  2. Submit Student Application Part 2: Household Information (this form)

Upward Bound staff will review all completed applications for initial eligibility. Students determined to be eligible will be invited to interview with a program staff member. Following the interview, staff will work with the student to request and obtain a school counselor report and teacher recommendation. 

Admission into the programs is based on financial eligibility, academic eligibility, and the personal interview. 

STUDENT APPLICATION PART 2

 To be completed by the parent/guardian.

All fields of the application are required to determine program eligibility.
Information provided is protected by the Privacy Act.

Student Name
Student's Legal First Name *
Preferred/Chosen First Name
Student's Legal Middle Initial
Student's Legal Last Name *
With whom does the student live primarily? *

Parent/Guardian Information

The following questions relate to Parent(s)/Guardian(s) with whom the student primarily lives.
Parent/Guardian 1 in Primary Residence (P/G1)
First and Last Name *
Relationship to Student *
Cell Phone *
Email Address *
Highest Educational Level Completed *
Occupation
Parent/Guardian 2 in Primary Residence (P/G2)
First and Last Name
Relationship to Student
Cell Phone
Email Address
Highest Educational Level Completed
Occupation

Household Size
How many people live in the student's primary household? *

In the space below, please list the names, ages, and the relationship to the student of the individuals living in your primary residence. 

Example: Susan Smith (sister, 8)

Do not include the student or the Parent(s)/Guardian(s) listed above.
Full name (relationship, age)

Income Information

Please complete the following questions necessary to determine income eligibility for the Upward Bound Programs. The questions relate to Parent(s)/Guardian(s) with whom the student primarily lives (those who are listed above).

Note: If you are unable to upload income verification documents while completing this form, please continue and submit the application. After receiving your application, a staff member will contact you for alternative methods for submitting tax returns, statements, etc. 
Dependency Status
Is the student currently a ward of the state/court or in foster care? *
Please upload a copy of statements verifying student's status as a ward or youth in foster care.
Is the student currently homeless? *
Please upload a copy of statements verifying student's status as homeless.

Household Income

Note: For students who are wards of the court, in foster Care, or homeless under the McKinney-Vento Homeless Assistance Act, household income information is not required. Please see documentation requirements listed above.
Are/were you required to file a Federal Income Tax Return (1040)? *
If yes, please list the Taxable Income from your most recently submitted tax return (IRS Form 1040, line 15)
Please upload a copy of your most recently submitted tax return(s) for verification.
If no, what were the household's income sources for the last calendar year?
Please upload a copy of statements verifying the above income sources.

AUTHORIZATION TO RELEASE INFORMATION

By signing below and submitting this application, I hereby authorize any educational institution that my student attends or will attend to release the following academic record information to the Keene State College Upward Bound Programs:

  • grades,
  • grade reports (report cards),
  • transcripts,
  • course schedules,
  • attendance records,
  • disciplinary records,
  • individual education plans and 504 plans,
  • standardized test scores,
  • proof of graduation,
  • proof of enrollment,
  • academic progress toward graduation, and
  • financial aid.

I also authorize program use of school information systems (e.g. Power School, Jumprope, Enriching Students, Web2school) to access my student's academic records.

I understand that the United States Department of Education requires the Upward Bound Programs at Keene State College to report on students' academic eligibility and progress from point of admission through either their graduation from college or for at least six years after graduation from high school, and that this information will be handled in strict confidence according to federal regulations.

CERTIFICATION

 All of the information in this application is true and correct to the best of my knowledge. If asked by an authorized official, I agree to give proof of the information provided on this application.
Parent/Guardian Signature *
Signature Type: Simple    Start Over
Click here to start signing.
  • Pencil
  • Reset
Signature: (Type in your full name)
I agree to the terms included.

APPLICATION SUBMISSION

 Click the button below to submit Student Application Part 2.