Upward Bound Student Application UB Application Heading link Copy link Step 1 of 3 33% Name * Required First Middle Last Pronouns Date of Birth * Required MM slash DD slash YYYY Gender * Required Male Female Address * Required Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home Telephone NumberStudent Cellular Phone NumberStudent E-mail * Required Parent Cell Phone Number * RequiredParent/Guardian E-mail * Required Do you have any mental, physical and/or learning disabilities? * Required Yes No If yes, please explain:Ethnic-racial background * Required Native American Indian African American Hispanic Asian American White/Caucasian Hidden Is the participant eligible to apply for financial aid? * RequiredEligible persons are or has US National Permanent Resident Card, Resident Alien Card, Alien Registration card, or Arrival Departure Record Yes No High School Name * Required High School AddressCurrent Grade Level: * Required 9 10 11 12 Current G.P.A.: * Required Mother’s Name: * Required First Middle Last Father’s Name * Required First Middle Last Legal Guardian’s Name: * Required First Middle Last Student lives with: * Required Both Parents Father Mother Stepmother Stepfather Legal Guardian Foster Home Other(Specify) Emergency Contact Name: * Required Telephone Number(s): * RequiredEmergency Contact’s Relationship to Participant: * Required School Counselor's Name * Required School Counselor's Email * Required Teacher's Name * Required Teacher's Email * Required Student EssayIn the space below, write a brief essay stating your career interests, hobbies and goals, as well as why you are interested in participating in this program. This essay must be written by the student, without assistance from anyone (use only the space provided below). * Required Parental IncomeChoose one of the following options * Required Father Male Guardian Mother Female Guardian Name * Required First Middle Last Contact Number, choose one of the following * Required Home Phone Number Cell Phone Number Home PhoneCell PhoneParent Home Address * Required Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Currently Employed * Required Yes No Occupation Employed by Number of years employed by the firm Gross weekly income ($) Number of work hours per week Check any that apply to the student Father deceased Mother deceased Parents separated Parents divorced Parents never married Non-Taxable IncomeGive MONTHLY amounts for each source of non-taxable income being received by your family from any of the following, including applicant’s shareDo you receive any non-taxable income? * Required Yes No Enter Amounts for the all the fields belowSocial Security Income * Required Public Aid * Required Veteran's Benefits Unemployment Benefits Alimony/Child Support Other Non-Taxable Income (pension, retirement, etc.)Taxable IncomeTaxable Income Before Deductions Total 2022 (1040 - Line 15, 1040E2 - Line 4) Father, Male Guardian $Total 2022Mother, Female Guardian $Total 2022Total Taxable Income * Required $Total 2022Family InformationPlease list below the dependent children and other individuals whom the parent/guardian supports. * RequiredFirst and Last NameAgeRelationship If there are any special family concerns that should be taken into consideration in the processing of this application for your child, please explain in the space below. Whenever possible, show why these problems affect you financially.What is the highest grade level achieved by your mother or female guardian? What is the highest grade level achieved by your father or male guardian? Acknowledgement I declare, to the best of my knowledge, that the information on this financial statement in true, correct, accurate, and complete. I agree to provide additional documentation, if necessary, to verify that the information reported in this statement is true. Medical ConsentFamily Medical HistoryPlease list any of the following that your mother, father, brother(s), sister(s) ever had I.E : Cancer, Diabetes, High Blood Pressure, Tuberculosis, Epilepsy, Mental Illness, Goiter, Stroke, Heart Disease, Nephritis, Serious Allergies, OtherPast HistoryPlease list any significant Illnesses/Surgeries that the participant has had. Include accidents, deformities, allergies.Parental Permission * Required PARENT SHOULD CHECK THE BOX TO GIVE CONSENT FOR SUCH MEDICAL PROCEDURES AS MAY BE DEEMED NECESSARY FOR THE CHILD. The law requires that parental permission be obtained for medication, emergency treatment and operative procedures on minors. The parents should sign the following consent form so that emergency procedures may be carried out promptly, and so that no unnecessary delays occur with less urgent operative procedures. However, no operations will be performed, except in an extreme emergency without parents being contacted and fully informed. Authorization to Release Information * Required I hereby authorize any educational institution that I am attending or will attend to release information regarding my enrollment status, school transcripts, copies of Math, Science, and Reading diagnostic test scores, and any other pertinent information to the University of Illinois at Chicago Upward Bound Program. I understand that this information will be kept confidential and be used to maintain follow-up data and for general reports to the United States Department of Education. Release of Media * Required I, the undersigned, voluntarily grant to the University of Illinois at Chicago, without compensation, the permission to use photographs, videotape, audiotape, name and/or basic information about myself to illustrate its programs and services. Student's Name * Required First Last Student Signed Date * Required MM slash DD slash YYYY Parent's Name * Required First Last Parent Signed Date * Required MM slash DD slash YYYY