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Upward Bound Student Application

Deadline: October 3, 2018

Upward Bound-North Central Missouri College

1301 Main Street Trenton, MO 64683 (660) 357-6353
caustin@mail.ncmissouri.edu

For more information: Visit the Upward Bound website

Please download, print and complete the form. Return to your counselor.
Download this form 


Student Information

Name:


(Last, First, Middle Initial)
Mailing Address:


(# & Street/PO Box, City, State, Zip)


Phone Number:


Email Address:


Birth Date:


(mmddyyyy)
Gender:
Male   Female

U.S. Citizen:
Yes   No

Racial Information: (please mark yes or no for each category)

American Indian/Alaskan Native Yes  No

Asian  Yes   No

Black or African American Yes   No

White Yes   No

Native Hawaiian or Other Pacific Islander  Yes   No

Is English the primary language spoken in your home? Yes   No

Are you, the applicant, of Hispanic/Latino descent?  Yes   No

High School:


Present Grade:   Ninth   Tenth   Eleventh

Do you have a documented disability?  Yes   No
If Yes, please list:


How did you hear about the Upward Bound program?


Do you know of anyone that was/is currently in Upward Bound?


Income Information

The following line numbers correspond to taxable income. Please review your most current federal income taxes for this information:


I filed a 1040. Form line #43

$


or
I filed a 1040 A. Form line #27

$


or
I filed a 1040 EZ. Form line #6

$


or
I did not file an income tax form last year. Gross Income
$


Number of members in household including applicant


I certify the income information provided is what is documented on my federal income taxes.
Parent/Guardian Signature:


Family Information

Biological/Adoptive Fathers Name


Occupation/Employer


Home Phone


Cell Phone


Email Address


Biological/Adoptive Mothers Name


Occupation/Employer


Home Phone


Cell Phone


Email Address


With whom does the student live?  Mother   Father   Both   Legal Guardian   Other

Student’s natural/adoptive father:

Did not graduate from high school
Graduated from High School/GED
Completed an Associate’s Degree (2 year)
Completed a Baccalaureate Degree (4 year)

Student’s natural/adoptive mother:

Did not graduate from high school
Graduated from High School/GED
Completed an Associate’s Degree (2 year)
Completed a Baccalaureate Degree (4 year)

According to the Code of Federal Regulations, Upward Bound 645.6: Potential first-generation college student means—

  1. An individual neither of whose natural or adoptive parents received a baccalaureate degree; or
  2. A student who, prior to the age of 18, regularly resided with and received support from only one natural or adoptive parent and whose supporting parent did not receive a baccalaureate degree.

Under this definition, this applicant is a “first generation college student.” Please select one:  Yes   No

 


Print name


Parent/Guardian signature

BY SIGNING BELOW I UNDERSTAND THE UPWARD BOUND PROGRAM:

  • Is a commitment that I will participate in for the remainder of my high school career.
  • Is a college preparatory program. Therefore, I will not be able to participate in this program if I do not plan on enrolling into postsecondary education immediately following high school graduation.
  • Is a program that I will need to actively participate in during the academic year. This includes weekly after school tutoring, monthly Extreme Saturdays, monthly school visits, and weekly contact with the Upward Bound staff.
  • Is a program that I will need to actively participate in during the summer component. This includes a five week residential hall stay on the North Central Missouri College campus and an end of summer out of state cultural trip.

I certify that all information provided on this application is current and correct to the best of my ability.

I hereby give my permission for the high school guidance office to send a copy of my course schedule, transcript, disciplinary status, absent report, and test scores to the Upward Bound program at North Central Missouri College. That information and the information contained in this application, is for the use of Upward Bound program only and
will be held in the strictest confidence. (Note: For our own records, it is necessary that you complete this form in its entirety.) We certify that the information contained on this form is correct and complete to the best of our knowledge by affixing our signatures below.

The parent/guardian agrees that his or her teen’s image may be used to promote the North Central Missouri College Upward Bound Program.


Student’s Signature & Date


Parent/Guardian’s signature & Date

ALL INFORMATION IS CONFIDENTIAL