Senior Exit Form | Arizona Western College

1 Start 2 Complete

Upward Bound and the US Department of Education track all Upward Bound students for a six-year time period following their exit from the program. This enables Upward Bound to stay in contact with its graduates and also helps the Department of Education measure the effectiveness and success of the program.

We ask that all Upward Bound Alumni complete this exit form for program record-keeping and tracking purposes. All information will be kept confidential from anyone outside of the AWC Upward Bound program.

Last Name: *

Please include full legal name.

First Name: *

Middle Initial:

Address *

City *

Zip Code *

Date of Birth: *

Month

Day

Year

Email: *

Personal email – not school email

Phone:

High School *

Graduation Year *

Post-Secondary Plan: *

College

University

Military

Employment

Name of School:

I plan to attend:

Full Time

Part Time

I applied for Financial Aid: *

Yes

Additional Contact Information

Please provide two additional options to contact you. This could be grandparents or other relatives that would know your contact information in six years.

Name:

Relationship:

Phone:

Name:

Relationship:

Phone:

By signing this form, I hereby authorize the release of:

ENROLLMENT STATUS (Including PT/FT status, Program of study, completed credits, and anticipated graduation date)
COLLEGE FINANCIAL AID RECORDS
CLASS SCHEDULE

I further authorize the Arizona Western College Upward Bound Program to photocopy this form and submit it to any institution. I understand that some of my records may be protected under the Family Educational Rights and Privacy Act of 1974 and cannot be released without my written consent. I hereby waive all provisions of the law and privilege relating to the records described in this disclosure. I certify that this consent has been given freely and voluntarily. I may revoke this consent at any time by providing written notice of such revocation to AWC Upward Bound office or person who maintains the records of this authorization. This authorization is good for six years after High School graduation. The person and or agency receiving this information may not disclose the information received as a result of this disclosure unless specifically authorized in the “purpose” section of this release.

Student Signature

Signer Name *

Leave this field blank

Contact Info

Email: upward.bound@azwestern.edu

Phone: (928) 317-6036

Fax: (928) 344-7755

Location: Yuma: ES 114; Parker: Community Center

Hours:

Monday - Thursday: 7:00 am - 5:00 pm

Additional Contact Information

Contact Info

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