Thank you for your interest in our Upward Bound program!  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. 


Chemeketa TRIO Upward Bound Application

 General Information:

First Name *
Last Name *
Middle Name
Date of Birth *
Gender *
Race/Ethnicity *
Address 1 *
Address 2
City *
State *
Zip *
Email *
Home Phone *
Cell Phone Number
Residency Status of Student *
Describe your primary reason for applying *

Academic Info:
Current Grade Level *
Current School Attending *
Student ID
Have you passed the SBAC in Reading/Language Arts *
Have you passed the SBAC in Math? *
Have you completed Pre-Algebra with a grade of C or higher? *
Have you completed Algebra I with a grade of C or higher? *

Family Information:

For Annual Taxable Income below, please do not use Adjusted Gross Income or Net Income. The correct figure must be Annual Taxable Income. This is found on Line 43 of the 1040 or Line 27 of the 1040A or Line 6 of the 1040EZ. Please also upload a copy of the first 2 pages of the parent/guardians' most recent 1040 tax form to confirm this information. If you are unable to upload this document, we can make other arrangements.

Parent Name (First / Last)
Parent Phone Number
Has either parent completed a 4-year Bachelor's Degree *
How many people in your household? *
Annual Taxable Income *
Recent 1040 or similar tax document

Student and Parent Agreement:

The Chemeketa Community College TRIO Upward Bound program is an outstanding college preparation program available to only 74 qualified students from three local high schools. In order to ensure that we enroll qualified students who will benefit from all of the resources and opportunities available through Upward Bound, it is very important that students fully understand their commitment.  Please read this with your parents, check each box to agree with each statement.

I understand that Upward Bound is an academic program and academics comes first.
I will complete high school and pursue post-secondary education
I understand I must maintain at least a 2.5 or higher GPA throughout high school
I will attend weekly tutoring meetings
I will attend all individual meetings with my UB advisor
I will attend all Upward Bound Saturday events
I will attend the six-week Upward Bound Summer Academy
I will abide by all rules and regulations of Upward Bound and Chemeketa Community College
Poor attendance, lack of participation, or behavioral issues will be a basis for dismissal from Upward Bound.


Academic Records Release:

In addition to the student agreement above, Upward Bound will need to obtain information from other sources to meet the needs of our students and the reporting requirements of the U.S Department of Education. We gather information from high schools, colleges, testing institutions, and other agencies or universities on behalf of our students and program. Your signatures on this application authorize Upward Bound to:

Request copies of your academic transcripts and test scores from your school(s) and/or the district.
Request a copy of your test scores, including ACT, SAT, AP/IB, and others.
Request copies of your financial aid application, transcripts, college enrollment status and awards from the federal & state funding agencies, post-secondary institutions, and the National Student Clearinghouse
Communicate with representatives from agencies, post-secondary institutions on your behalf

I hereby authorize Upward Bound to contact and request information from, as well as to share information with, the above mentioned parties. I give my son/daughter permission to participate in Upward Bound activities, if accepted. I also give permission for my son/daughter to be interviewed, photographed or videotaped by Upward Bound for use in program promotional materials and documentation, if accepted. Our signatures below indicate our commitment to the Upward Bound Student and Parent Agreement. To the best of my knowledge, all the information I have provided in this application is true.

Sign and Submit:
Student Signature *
Please select a signature verification type.
Parent/Guardian Signature *
Please select a signature verification type.