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

STUDENT APPLICATION

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

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


SECTION 1: STUDENT INFORMATION

To be completed by the student.


Student's Legal First Name *
Student's Preferred First Name
Student's Legal Middle Initial
Student's Legal Last Name *
Suffix (Jr., III, etc.)

Contact Information

Mailing Address or P.O. Box *
Apt/Unit #
City/Town *
State *
Zip Code *
Home Phone
Student's Cell Phone Number
Student's School Email Address
Student's Personal Email Address

Demographic Information

Gender *
Date of Birth (MM/DD/YYYY) *
Citizenship *
Primary Language Spoken at Home *

Race & Ethnicity

Choose "1" if you identify "YES" or choose "2" for "NO"

Hispanic *
American Indian/Alaskan Native *
Black or African American *
Black or African American *
White *
Native Hawaiian or Other Pacific Islander *

Educational Information

High School the Student Attends/Will Attend *
Expected Year of High School Graduation *
Name of School Counselor *
NH students: Are you a participant in UNH ETS (Educational Talent Search)?
VT Students: Are a you a participant in the VSAC Outreach program at your school?

SECTION 2: HOUSEHOLD INFORMATION

To be completed by a parent or guardian.



With whom does the student live at the address listed above? *
How many people live in the household listed above? *

Parent/Guardian Information

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

Additional Household Members

Please enter the names and ages of household members. [Example: Susan Smith (sister, 8)] Do not include student or parent(s) listed above.

Household Income Information

Please complete the following questions necessary to determine income eligibility for the Upward Bound Programs. 

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. 

Are/were you required to file a 2021 Federal Income Tax Return (1040)? *
If yes, please list the Taxable Income from 2021 (IRS Form 1040, line 15)
Please upload a copy of your 2021 tax return(s) for verification.
If you were not required to file a 2021 Federal Income Tax Return, what were the household's income sources in 2021?
Please upload a copy of statements verifying the above income sources.
Is the student currently in foster care, been in foster care at any time after the age of 13, or homeless? *
Please upload a copy of statements verifying student's status as foster care youth or homelessness.

SECTION 3:  AUTHORIZATION TO RELEASE INFORMATION


By signing below and submitting this application, I hereby authorize any educational institution that I am attending 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 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.


SECTION 4:  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.

Student 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.
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.