|
Upward Bound Program Application |
Dear Student,
Thank you for your interest in the Upward Bound Program sponsored by Pueblo Community College. Upward Bound is a federally funded program designed to prepare eligible high school students for college.
Program services include, but are not limited to: tutoring, academic instruction, cultural enrichment, career exploration, financial aid application assistance, college visits, and support services designed to assist students as they prepare for entry into and ultimately graduation from college.
We hope that we will have the opportunity to assist you as you pursue your educational goals. Each item listed below is necessary for consideration for the Upward Bound Program. Once you have completed the enclosed information, please return it to Pueblo Community College Upward Bound Program, 900 W. Orman Avenue TE-118, Pueblo, Colorado, 81004. To speed up the process of reviewing this application, we ask that you return the information COMPLETED AND SIGNED AS SOON AS POSSIBLE.
1. Counselor Recommendation (completed by counselor),
2. Student Application (completed by student),
3. Parent Financial Report (completed by parent),
A. Current income tax form
OR,
B. Letter of fixed income,
4. Signed Transcript Release Form & Transcript (should be given to counselor, with attached forms),
5. Achievement Scores,
6. Most Recent Report Card.
If the application is not complete, or is missing income information, transcripts, etc., it CANNOT be processed. Information not relative to your status must be filled in with N/A. Please call us with any questions or for help in completing this application at 549-3463.
PUEBLO COMMUNITY COLLEGE UPWARD BOUND PROGRAM APPLICATION FORM
PRIVACY ACT - The personal information you give to the Upward Bound Director is sent to the Federal Government (Department of Education). The Privacy Act protects the information. No one may see the information unless they work with or for the Upward Bound program or are specifically authorized to see the information. The information is necessary to determine if you are eligible to participate in the program and help the government to measure your success. The Department of Education has authority to gather information to help make Upward Bound a better program. (20 USC 1231A).
Name:
First ______________________________________
Middle ____________________
Last ______________________________________
Social Security No: ________________Date of Birth _______Age_______
Address: _________________________________ City: ____________________
State: _____ Zip: ________Phone (Home): ___________(Work)____________ (cell)___________
Emergency Contact: ______________________________Phone: ____________
E-mail address ________________________________________________________
Are you living at home?_____ If not, list parents/guardians name, address, and phone:________________________________________________
___________________________________________________________________
Ethnicity: Black___ White___ Chicano/Hispanic___ Asian__ Native American__ Other__
Female__ Male__ U.S. Citizen: Yes___ No___
School Information:
Name of High School: __________________________
Address: ___________________________City: ______________Zip: ________
Grade: 8th____ 9th____ 10th____11th____ 12th____Expected Graduation Date: ______________
What subjects do you perform well in? ____________________________________
And why? __________________________________________________________
What subjects do you have difficulty in? ___________________________________
___________________________________________________________________
And why? ___________________________________________________________
What athletic interests do you have? ______________________________________
What clubs or activities do you participate in? _______________________________
Are you presently employed? _____________ Where: ________________________
How many hours a week do you work? ____________________________________
Without the Upward Bound assistance it may be difficult to complete high school:
Yes____ No ____.
I need Upward Bound assistance for education beyond high school:
Yes____ No____
I understand the purpose of the Upward Bound Program. If accepted, I agree to participate fully in all academic, and social programs. I further agree to comply with all rules and regulations established by the Coordinator and staff of the Upward Bound Program, with the understanding that failure to comply could result in dismissal from the program.
Applicant Signature____________________________ Date______________
To be considered for the Upward Bound Program, the applicant must answer the following four questions:
1. What are several goals you would like to accomplish while participating in this program
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________ ____________________________________________________________________
2. Why do you consider these goals important?
____________________________________________________________
____________________________________________________________
____________________________________________________________ ____________________________________________________________
3. What career do you want to get into after graduation, and what plans have you made for achieving this goal?
_____________________________________________________________
______________________________________________________________
______________________________________________________________
4. Would you be willing to make a commitment to summer school for 6 weeks each summer?
______________________________________________________________________ ______________________________________________________________________
_______________________________________________________________
______________________________________________________________
PUEBLO COMMUNITY COLLEGE PARENT'S FINANCIAL REPORT TO
UPWARD BOUND PROGRAM
THIS PART OF THE FORM IS TO BE FILLED OUT BY THE PARENTS OR GUARDIAN:
The following information is required by the Federal Government to determine low-income status, and must be accurate and exact. Your answers will be held in strict confidence. The Privacy Act (20 USC 1231 A).
Student's Name: ____________________________________________________
Parent's/Guardian Name: ____________________________________________
With whom does the student live: (check box)
□ Mother & Father □ Mother & Stepfather □ Mother □ Guardian
□ Father & Stepmother □ Father
□ Other: Explain_______________________________________________
|
Additional income (per month):
Part-time employment $________ Pension $_______
Military pension $________ Welfare $_______
Social Security $_________Child Support $_______
***Taxable Income $______________
|
***Taxable Income from (Line 36 on 1040 & Line 19 on 1040A)
Number of dependents claimed on Income Tax Report: _______________
Please list all children or dependents that live with you:
|
Name |
Age |
Relationship |
Occupation |
Highest grade completed |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Parents Insurance Company:______________________ #_______________
For Identification: MEDICAID #____________________________________
I authorize my daughter/son to be treated by qualified Southern Colorado Medical personnel, St. Mary Corwin or Parkview Hospital in Pueblo, while engaged in official Upward Bound activities. I will not hold the Pueblo Community College, Upward Bound Program, and its agents responsible for acts in which they have no control.
PARENT’S SIGNATURE_______________________________DATE: ___________
Does Father or Mother have a Bachelors Degree? Yes _____ No ______
Parent’s or Guardian’s Occupation: ______________________________
IF APPLICANT IS A WARD OF THE COURT OR IN A FOSTER HOME, PLEASE COMPLETE THE FOLLOWING:
Name Resident Agent: _________________________________________________
Case Worker:___________________________________ Phone:_______________
Please give a brief history of this placement: ________________________________
___________________________________________________________________
___________________________________________________________________
*******************************************************************
READ THE FOLLOWING STATEMENTS AND SIGN BELOW:
The Upward Bound Program is administered and co-sponsored by the Department of Education of the United States Government. Financial information contained in this document may be confirmed through your Bureau of Internal Revenue Income Tax Return. (Please submit a copy of your most recent Income Tax Return, or a current letter of Fixed Income). YOUR STUDENT CANNOT BE ACCEPTED TO PARTICIPATE IN UPWARD BOUND UNTIL THIS INFORMATION IS RECEIVED.
STUDENT'S NAME: ______________________________ has permission to be a participant in the Upward Bound Program. It is understood that we agree to his/her participation in all activities, whether academic or cultural, both on and off the Pueblo Community College campus.
SIGNATURE OF PARENT/GUARDIAN______________________________________
DATE_________________
_________________________________________________________________________________
PUEBLO COMMUNITY COLLEGE
UPWARD BOUND PROGRAM
HIGH SCHOOL COUNSELOR INFORMATION
Counselor - Please complete all information below!
Counselor's Name: _________________________________________________
Name of School: _________________________________________________
Applicant's Name: _________________________________________________
GPA Information a necessity for application to be complete
GPA: ______________________________ As of (Date) __________________
Cumm. GPA: ________________________ As of (Date) __________________
Is this student outstanding in any academic or vocational area?
__________________________________________________________________
List the subjects currently being taken, below:
Subject: Teacher: Subject: Teacher:
Credits obtained: ____________ Credits attempted: __________________
Is this student credit deficient? Yes__________ No_____________
If yes, how many credits: ________
******************************************************************************************
Please attach copies of student's (1) Transcripts (2) Recent grades
(3) Achievement scores (4) any other scores pertinent to student.
******************************************************************************************
Are there any home or personal problems that may affect this student's progress: _____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
General Comments: (Attitude, etc.)__________________________________________________
_____________________________________________________________________________
_______________________________________________________________________________
Do you recommend this student to Upward Bound? Yes____ No____(Student must demonstrate academic potential)
Remarks: (Why or why not)________________________________________________________
___________________________________________________________________
Counselor's Signature: ____________________________ Date:
************************************************************************************************************
Office Use:
Accepted: _________ Date: _________ Coordinator Signature: __________________________
1. Low Income _____
2. First Generation _____
3. Academic Need _____
4. Additional Information: ________________________________________________________
________________________________________________________________
************************************************************************************************************
PLEASE GIVE THIS FORM TO YOUR COUNSELOR.
Please send official transcripts to:
UPWARD BOUND PROGRAM
PUEBLO COMMUNITY COLLEGE
900 W. ORMAN AVE.
PUEBLO, CO 81004
School Records Release Form
Authorization to release records of__________________________________________________
I hereby authorize hat PCC Upward Bound staff members have access to the student records that are checked below:
q High School transcript (including name of parents, address, attendance records, courses taken, grades obtained, standardized test scores, etc.)
q Individual Education Plan and/or diagnostic data, including learning skills assessments.
q Other student records _____________________________
In addition, I authorize PCC Upward Bound staff to receive information from high school teachers, counselors and other high school personnel on the above-named student’s academic progress and/or academic concerns.
This release form granting permission is in effect until I notify the school in writing that the permission has been rescinded.
Student's Signature: _______________________________ (If student is 18 or older)
Parent's Signature: _______________________________
Date Requested: _______________________________
100% federally funded with a budget of $294,425 serving 60 students.