2022-2023 Daytona State College

TRiO Upward Bound

Participant Application

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. 


General Information:

The Daytona State College (DSC) TRiO Upward Bound program identifies and assists Mainland High School students who have the interest and potential to succeed in higher education. The program provides academic, career, and financial counseling to its participants and encourages them to graduate from high school and enroll in the post-secondary institution of their choice. Students must be in grades 9 - 12 and attend Mainland High School.

For more information please visit our website:


If you have any questions, please call our office at (386)506-3635.




The following section is to be completed by the student:

Please upload a copy of the student's most recent report card/progress report below:
Report Card Upload *
Student's Last Name *
Student's First Name *
Student's Middle Name
Student Date of Birth (05/01/2006) *
Student's Current Age: *
Address 1 *
Address 2
City *
State *
Zip *
Home Phone
Student's Cell Phone Number
Student's School Email *
In the space below or on a separate typed sheet, please answer the following questions in essay format. 1) Why are you applying to the Daytona State College Upward Bound Program? 2) What are your academic strengths and challenges? 3) What are your career interests? 4) Why should we accept you? *
Student Essay Upload:

Academic Info:
Current Grade Level *
Current School: *
Student's Current GPA: *
Student's Gender: *
Student's Ethnicity(American Indian/Alaska Native, Black/African American, Asian, Native Hawaiian/Pacific Islander, White, or Other): *
Is the student a US Citizen? *

Student Personal Data Form
Check box or enter (type) all that apply.
Can the student swim? *
Within 3 months after graduating from high school, I plan to: *
List your school and community activities (clubs, student government, athletics, organizations, etc.) *
Identify awards and honors you have received. *
Using the scale below, how would you rate your academic ability and motivation?
Academic Ability: *
Motivation: *
Describe any special interests or hobbies you have. What do you do after school and on weekends?: *
Please select any courses the student has completed or is currently enrolled in:
Algebra I
Algebra II
Please list any other higher level mathematics, science, or foreign language courses the student has completed:
Dual Enrollment Participation *
Have you ever been convicted of a misdemeanor, felony or other crime? *
If yes, please explain the nature of the incident(s).
Please select the area(s) you would like assistance with:
Financial Aid & Scholarships
Choosing Courses
Goal Planning
Time Management
Career Exploration
Study Skills/Note Taking
Public Speaking
Test Prep
Improving your grades

The following information is to be completed by the student's legal parent or guardian.

The personal information, including financial status and educational levels provided below, is used for reporting purposes with the Department of Education. The information is required to determine eligibility established by regulation of the Department of Education and will remain confidential and is protected under the Family Educational Rights and Privacy Act (FERPA, 20 USC 1231a). All information is required for the student to be considered for this program.


Household Taxable Income

Please note that Taxable Income is usually LOWER than the Adjusted Gross Income. Taxable Income can be found on line 15 of the IRS 1040 tax form for 2021. If you have any questions, please call (386) 506-3635. 

There are two options for verifying taxable income and an additional option if no taxes were filed last year.

You only need to complete one of the following three options:

Option 1: Self-report household income information by selecting the correct option in the drop-down below.

Option 2: Attach last year’s tax form in the indicated space below.

Option 3 - If the student's household did not submit a tax form last year, enter self-report income information in the indicated box.

Option 1: How many people in your household? *
Option 1: Family Income Range *
Option 2: Household Taxable Income upload
Option 3: If you did NOT file a tax form, complete the following:
OtherNon-taxable Income: $ (Disability, AFDC, Veteran Benefits, Retirement, Unemployment)
Does the student or the student's family receive assistance from any of the following?
Not Applicable
Social Security Insurance
Veteran's Benefits
Food Stamps/SNAP/WIC
Public Assistance (Wellfare/A.F.D.C./TANF)
Free or Reduced Lunch Program
Please read the following statement, then sign and date. By signing this Income Verification Form, I am verifying that the information that I have provided to the DSC TRiO Upward Bound program is true and correct. This information is protected by the Privacy Act. No one may see the information unless they work with or for the DSC TRiO Upward Bound Program, or are specifically authorized to see it.
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.
Part II: Family/Parent Informtion Continued

Parent/Guardian 1 Information

For Parent/Guardian 1 information, please enter the information of the primary parental contact for the student.

Parent/Guardian 1 Name: *
Has the student's Parent/Guardian 1 completed a 4-year degree? (This means a bachelor's degree or higher level.) *
Parent/Guardian 1 Email: *
Parent/Guardian 1 Street Address (include apartment or lot number if applicable): *
Parent/Guardian 1 City: *
Parent/Guardian 1 State (ex. FL) *
Contact 1 Zip *
Parent/Guardian 1 Cell Phone *
Parent/Guardian 2 Information
Parent/Guardian 2 Name: *
Has the student's Parent/Guardian 2 completed a 4-year degree? (This means a bachelor's degree or higher level.) *
Parent/Guardian 2 Email *
Parent/Guardian 2 Street Address (include apartment or lot number if applicable): *
Parent/Guardian 2 City: *
Parent/Guardian 2 State: *
Parent/Guardian 2 Zip Code: *
Parent/Guardian 1 Cell Phone *

The student applying to Upward Bound has my permission to be a participant in the Daytona State College
Upward Bound Program. It is understood that I agree to his/her participation in all activities, whether academic,
civil or recreational, both on and off the Daytona State College campus.

In case of an emergency during and official Upward Bound activity, I authorize my son/daughter to be treated
by qualified medical personnel.

In order for my student to participate in the Daytona State College Upward Bound Program, I agree to the following statements:

  • I understand that Upward Bound is a college preparatory program and that by applying to Upward
    Bound my student is agreeing to participate throughout their high school years, both during the academic year and six weeks in the summer.
  • I understand that after high school graduation, my student will enroll in some form of postsecondary education.
  • I understand that the Upward Bound Program is an academic program that assists and tracks students’ progress in academic pursuits while in high school and throughout college.
  • I understand that I am required to attend both Summer and Fall UB Orientations with my student.
  • I understand that I am required to attend a parent/student academic conference once a semester.
  • I commit to supporting my student by encouraging them to fulfill all requirements of the Upward Bound
    Program. This includes maintaining a 2.5 GPA per semester, attending scheduled Saturday sessions during the school year, extra tutoring when necessary, service learning projects, and other cultural activities.
  • I commit to attending monthly Upward Bound Parent Support Committee meetings.
  • I understand that I am responsible for informing UB staff of any changes regarding mailing address, email, and cell/home phone numbers.
  • I commit to supporting my student’s dream of post-secondary education.


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.
Complete the following questionnaire, explaining the importance of your child's participation in Upward Bound:
Why is your child’s participation in the Upward Bound Program important to you? *
What are your expectations of this program? *
What jobs or careers would you like to see your child pursue? *
After my child graduates high school, I expect him/her to: *

I understand that I must notify the Upward Bound office for any of the following reasons:

  • Change of address or phone number
  • Change of interest in the program
  • Transfer of school
  • Student’s acceptance into any other college educational preparation program
  • Student’s suspension or expulsion from school
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.
Please discuss your child’s readiness to attend a summer residential program: *
Please include any other comments or questions you may have regarding the program:

I hereby consent release of my secondary and post-secondary academic and student records to the
Upward Bound Program.

The Upward Bound Program requires my academic information to determine eligibility for admission; for advisement purposes while I am a high school student; annual reporting standards, and to track my progress towards completion of a post-secondary degree.
Access to my academic records is required by the Upward Bound Program’s funding agency (U.S. Department
of Education).
Information requested by the Upward Bound Program will include grade and progress reports, attendance and
behavioral records, transcripts, standardized test and assessment scores, special education records, enrollment
records, financial aid awards, and related material not otherwise listed.
I fully understand that the Daytona State College Upward Bound Program will request information for only the
purposes mentioned above, and that they will observe my confidentiality through the proper maintenance of records in secured files.

For more information, contact the TRIO Upward Bound Project Director at (386)506-3635 or email
Cassandra.Griggs@DaytonaState.edu, or visit DaytonaState.edu/Student-Resources/Trio/Trio-Upward-Bound

Parent/Guardian Signature *
Please select a signature verification type.
Thank you for your interest in the Daytona State College TRiO Upward Bound Program. If you have any further questions, please feel free to contact our office at (386) 506-3635. If your child is accepted, you may expect an email notification within 7 to 10 business days.