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* 1. First Name

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* 2. Last Name

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* 3. Date of Birth

Date

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* 4. Contact Information

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* 5. Do you have an A#?

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* 6. Best way to contact you (Check all that apply)

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* 7. Gender

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* 8. Ethnicity (Mark ALL that apply)

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* 9. Do you have a disability?

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* 10. Military Service (Select One):

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* 11. Branch of Service

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* 12. Discharge Status:

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* 13. Are you currently serving on active duty?

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* 14. Did you file taxes last year?

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* 16. What is your TAXABLE income (Total income MINUS all deductions):

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* 17. What is your current employment status?

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* 18. Did either of your parents graduate from a 4-year university?

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* 19. Did you:

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* 20. Date completed (Month/Year)

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* 21. Do you already have a college degree?

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* 22. Academic Goals (Check all that apply)

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* 23. List the names of any technical schools/colleges attended in the past:

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* 24. How did you learn about Veterans Upward Bound?

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* 25. PRE-PROGRAM ASSESSMENT

Rate your knowledge of the following subjects (choose one number per row):

  0 None 1 2 3 4 5 Some 6 7 8 9 10 Expert
Academic requirements for college
Admission to a college/university
Financial Aid
Veterans Benefits
Personal Finance
Veteran Serving Community Organizations

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* 26. How can VUB help you? (Check all that apply)

Academic Assistance:

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* 27. College Admissions:

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* 28. Financial Education:

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* 29. Community Resources:

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* 30. VUB PARTICIPANT CONTRACT
1. Each veteran enrolled in Veterans Upward Bound is required to actively participate in the educational plan which has been especially designed to meet their individual needs.

2. Any participant involved in the destruction or misappropriation of project or college equipment and materials will be liable for the same.

3. If you tell a VUB staff member or tutor that you are in immediate danger of hurting yourself or someone else, we will serve as mandatory reporters and are obligated to inform GSCC Administrators, security and call 911 for emergency assistance.

4.
Veterans Upward Bound is a joint program between Gadsden State Community College and the U.S. Department of Education and is solely dependent upon federal funds for its continuance. Gadsden State Community College and its personnel are in no way liable or obligated to continue program services if federal funds are terminated.

STIPEND POLICY
A stipend may be paid to eligible Veterans Upward Bound (VUB) project participants. In order to receive a stipend, participants must meet the following requirements:

1. Completion of a Pre-Program Assessment. A pre-assessment must be completed in order for a project participant to be eligible to receive a stipend.

2. Attendance. Project participants must utilize VUB services at a minimum of four hours per month in order to satisfy this requirement. VUB services utilized by participants may include counseling/advising, skills enhancement, instruction, tutoring, and participation in VUB-sponsored activities and events. All attendance (virtual or in-person) must be for activities legitimately related to grant services deemed allowable by the Department of Education.

3. Maximum monthly stipend allowed is $40.00. Eligibility for a stipend will be determined at the end of each month after preparation and approval of the monthly stipend verification form. Monthly payment amounts are calculated by minutes of documented participation (30min = $5.00). After approval by the VUB Director, a list of eligible participants and the stipend amount for each participant is forwarded to the Grants Budget Manager for final approval and forwarded for payment.

4. Payment. Stipend payments are issued by check from Gadsden State Community College and are payable to the participant. Stipend payments are mailed to eligible participants at the mailing address provided to VUB by the participant. Participants are responsible for updating address changes to ensure checks are promptly received.

5. Changes to Policy. Any changes to this policy must be approved by the VUB Director and the Dean of Institutional Effectiveness, Grants, and Special Projects.

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* 31. RECORDS POLICY:

I am hereby notified that the Department of Education is authorized to collect information, to implement the Veterans Upward Bound program under Title IV of the Higher Education Act of 1965, as amended (Pub. Law 102-325, sec. 402A and 402C). In accordance with this authority, the Department receives and maintains personal information on participants in the Veterans Upward Bound program. The principal purpose for collecting this information is to administer the program, including tracking and evaluating participants’ academic progress. The information will not be disclosed outside of the Department, except as allowed by the Privacy Act of 1974, pursuant to the routine uses identified in the System of Records Notice titled “TRIO Programs Annual Performance Report (APR) System (TRIO APR). I understand my photo may be taken at VUB events and used on marketing and social media. Choosing to opt out of photo opportunities during these events will be my own responsibility.

By typing my full name below, I verify that the information in this form is true and complete to the best of my knowledge.

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