In addition to your application, the following forms
Anuncio
Additional Documents Required In addition to your application, the following forms need to be submitted with this application package to determine eligibility: ☐ Signed copy of Parent’s/Guardian’s most recent federal Income Tax Return. ‐or‐ If the parent/guardian did not file an income tax statement, complete and sign the second page of application titled Parent/Guardian Information Form. ☐ Documentation of citizenship or residency: ‐Birth Certificate ‐Residency Card ☐ Copy of Social Security Card Upward Bound is 100% federally funded by a grant from the U.S. Department of Education Office of Post-secondary Education. Updated: June 11, 2014 Documentos Necesarios Estos tres documentos necesitan ser sométidas con esta aplicación para determinar elegibilidad: ☐ Copia de mas recientes declaraciónes de impuestos federaldes de Padres/Guardian ‐o‐ Si impuestos no fueron declardos llene la segunda página de la Forma de Información de Padres/Guardian ☐ Documentación de ciudadanía o residencia (por ejemplo: Certificado de Nacimiento) ☐ Tarjeta de Seguro Social Upward Bound is 100% federally funded by a grant from the U.S. Department of Education Office of Post-secondary Education. Updated: June 11, 2014 Midland College Upward Bound Dear Parent(s) and Student: It is my pleasure to introduce the Upward Bound program to you. Upward Bound is a federally funded college preparatory program for high school students. We offer services to a selected group of high school students who meet certain criteria. These services include Saturday academies during the school year, trips to college campuses, cultural activities, tutoring, a sixweek summer program, and our summer bridge component. Our goal is academic advisement as well as academic instruction for students through high school in order to prepare them for college curriculum and to track each student until they graduate from college. Students are selected for the program based upon a number of criteria, including their meeting federal income guidelines and/or being a first generation college student, as well as desire, dedication, and discipline to enter and graduate from college. We offer these services at no cost to the participant throughout high school and up to the summer after graduation, when Upward Bound covers some college expenses for Summer Bridge students. Upward Bound facilitates the process of college admission, financial aid, and the necessary testing to enter college. The participant also receives a stipend for participation in the program. We welcome your interest in our program and will be happy to answer any questions concerning the application process. We are limited to a small number of students we may serve from Midland, so if interested, please complete the attached forms and submit them for consideration for an interview and admission into our program. Thank you. Sincerely, Pervis D. Evans Pervis D. Evans Upward Bound Director Midland College (432) 686-4221 [email protected] 3600 N. Garfield PB 5 Midland, TX 79705 (432) 686-4215 Fax (432) 685-5507 Upward Bound is 100% federally funded by a grant from the U.S. Department of Education Office of Post-secondary Education. Updated: June 11, 2014 Midland College Upward Bound Estimado padre(s) y estudiante, Aprovecho esta oportunidad para introducir nuestro programa, Upward Bound. Upward Bound es un programa preparatorio de colegio financiados por el Gobierno Federal para estudiantes de secundaria. Ofrecemos servicios a un grupo de estudiantes de secundaria que cumplieron con los criterios seleccionados. Estos servicios incluyen sábado academias durante el año escolar, los viajes a los campus universitarios, actividades culturales, tutorías, un programa de verano de seis semanas y nuestro componente de puente. Nuestro objetivo es advisement académico, así como instrucción académica para los estudiantes a través de escuela secundaria para prepararlos para plan de estudios universitarios y hacer un seguimiento cada estudiante hasta que gradúan de la Universidad. Nuestras selecciones se basa en estudiante cumplir las directrices de ingresos federales o ser un estudiante universitario de primera generación, así como el deseo, la dedicación, disciplina para entrar y graduado de la Universidad. Ofrecemos estos servicios sin costo alguno al participante a través de sus años de escuela secundaria hasta el verano después de su graduación donde Upward Bound paga para la matrícula de verano para cada estudiante de puente. Enlazado al alza facilita el proceso de admisión de la Universidad a través de aplicaciones de ayuda financiera, aplicaciones de colegio y pruebas necesarias para entrar colegio. El participante también recibe un estipendio su participación en el programa. Damos la bienvenida su interés en nuestro programa y estará encantados de contestar cualquier pregunta sobre el proceso de solicitud. Estamos limitados a un pequeño número de estudiantes que nosotros podemos servir de Midland tan si está interesado, por favor completar los formularios adjuntos y someterlos a la consideración ser admitidos en nuestro programa. Sinceramente, Pervis D. Evans Pervis D. Evans Directora de Upward Bound Midland College (432) 686-4221 [email protected] 3600 N. Garfield PB 5 Midland, TX 79705 (432) 686-4215 Fax (432) 685-5507 Upward Bound is 100% federally funded by a grant from the U.S. Department of Education Office of Post-secondary Education. Updated: June 11, 2014 Today’s Date: _________________ Student Application Form (to be completed by STUDENT) NAME: Last First M. I. ADDRESS: 797 zip Date of Birth: Social Security: Place of Birth: City/Town Home Phone #: State Country Cell #: e-mail address: Student’s place of employment: Work phone #: Male Female Gender: Race/Ethnicity: (more than one race may be reported) American Indian or Alaska Native Asian Black or African American Hispanic or Latino White Native Hawaiian or other Pacific Islander Other (please specify)__________________________ Citizenship: Please respond to the appropriate categories (check one box per question): Are you a citizen of the United States? Yes No If no, are you a permanent resident of the United States? Yes No Alien Registration # A_____________________ If you answered “NO” to both of the questions above, please complete: I certify that I have been living in the United States with the intention of becoming a permanent resident. Applicant’s Signature:___________________________________________ (Please attach documentation from the U.S. Immigration and Naturalization Service to this application.) Is English spoken as the primary language in your home? Yes No If no, please specify the primary language____________________________ * Please provide a copy of Birth Certificate and Social Security card for verification. (CONTINUE ON BACK) Upward Bound is 100% federally funded by a grant from the U.S. Department of Education Office of Post-secondary Education. Updated: June 11, 2014 High School Information: Current year in school: 9 10 11 12 Student ID #______________ High School Name: ___________________________ Counselor Name:_______________ Personal Needs: Please list, in order, the careers or occupation you are most interested in: 1)____________________ 2)______________________ 3)________________ Please list, in order, the colleges, universities or technical schools you may be interested in attending: 1)____________________ 2)______________________ 3)________________ Please check all the academic areas you need assistance with (you may check more than one): English/Literature Mathematics Science Foreign Language Social Studies _________________ Other (specify) __________________ Please check from the following list so that we may assess your needs along with your strengths and weakness in order to develop an individualized plan for you. ____Study skills _____Time management ____Test-taking skills _____Career Development ____College planning ____ACT/SAT Preparation ____Scholarship/Financial Aid _____Using the Internet ____Tutoring LIST SUBJECT AREAS! 1._____________________ Comments:__________________________ 2._____________________ __________________________ 3._____________________ __________________________ I certify the above information is true and accurate to the best of my knowledge. Applicant’s signature__________________________________________________ Upward Bound is 100% federally funded by a grant from the U.S. Department of Education Office of Post-secondary Education. Updated: June 11, 2014 Today’s Date __________________ Parent/Guardian Information Form (to be completed by PARENT/GUARDIAN) Student’s Name: ______________________________________________________________ Last First Middle Father’s/Guardian’s Name _______________________________________________________ Address _________________________________________________________Zip_________ Home Phone: ___________________________ Cell Phone: __________________________ Employer________________________________________ Work Phone__________________ Highest Level of Education Attained ____Elementary Junior High: ___6 ___7 ___8 High School: ___9 ___10 ___11 ___12 ____GED ____Some college ___Associates Degree ___Bachelor’s Degree Mother’s/Guardian’s Name _____________________________________________________ Address _________________________________________________________Zip_________ Home Phone: ___________________________ Cell Phone: __________________________ Employer________________________________________ Work Phone__________________ Highest Level of Education Attained ____Elementary Junior High: ___6 ___7 ___8 High School: ___9 ___10 ___11 ___12 ____GED ____Some college ___Associates Degree ___Bachelor’s Degree Student lives with: __parents ___mother __father __guardian __other: ______________ I certify the above information is true and accurate to the best of my knowledge. Parent/Guardian Signature ________________________________________ Date___________ List other children, starting with the oldest: Name _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ Sex Age ___ ___ ___ ___ ___ ____ ____ ____ ____ ____ Living @ Home, College: Grade Level _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ ________ ________ ________ ________ ________ List other family/persons living in household: Name Sex ____ ____ ____ (Attach additional page if necessary) _____________________________ _____________________________ _____________________________ Age ___ ___ ___ Relationship to student ___________________ ___________________ ___________________ Grade Completed _______________ _______________ _______________ Upward Bound is 100% federally funded by a grant from the U.S. Department of Education Office of Post-secondary Education. Updated: June 11, 2014 Fecha de hoy: __________________ Información de Padres/Guardián (para ser llenada por PADRES/GUARDIANES) Estudiante: __________________________________________________________ Apellido Nombre Nombre de Padre/Guardián ____________________________________________________ Dirección domiciliario _______________________________________Código Postal _________ Teléfono domiciliario ___________________ Teléfono celular __________________________ Empleo ________________________________________ Teléfono _____________________ Nivel de educación más alto logrado ____Primaria ___6 ___7 ___8 Secundaria ___9 ___10 ___11 ___12 ___GED ____Algo de colegio ___Associates Degree ___ Bachelor’s Degree Nombre de Madre/Guardían_____________________________________________________ Dirección domiciliario _______________________________________Código Postal _________ Teléfono domiciliario ___________________ Teléfono celular __________________________ Empleo ________________________________________ Telefono _____________________ Nivel de educación más alto logrado ____Primaria ___6 ___7 ___8 Secundaria ___9 ___10 ___11 ___12 ___GED ____Algo de colegio ___Associates Degree ___ Bachelor’s Degree El estudiante vive con: __padres __ madre __ padre __ guardian __pariente o alguien mas Yo afirmó que esta información es cierta y precisa a lo mejor de mi conocimiento. Firma de padres: _______________________________________________Fecha:___________ Liste otros hjos , empezando con el mayor: Nombre _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ Sexo Edad ___ ___ ___ ___ ___ ____ ____ ____ ____ ____ Donde Vive Grado _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ ________ ________ ________ ________ ________ Liste familiares o gente quien vive con usted Nombre _____________________________ _____________________________ _____________________________ Sexo Edad ____ ___ ____ ___ ____ ___ (Adjuntar páginas adicionales si es necesario) Relación al estudiante Educación lograda ___________________ ___________________ ___________________ _______________ _______________ _______________ Upward Bound is 100% federally funded by a grant from the U.S. Department of Education Office of Post-secondary Education. Updated: June 11, 2014 INCOME ELIGIBILITY VERIFICATION (All Information is kept CONFIDENTIAL) Complete below if federal taxes WERE filed for most recent tax year and attach a signed copy of your tax return: Filing status: ___Single ___Married, filing jointly ___Married, filing separately ___Head of Household Total of number in household (exemptions): __________ Please check your TAXABLE family income for the previous tax year. (IRS Form 1040 line 43; IRS Form 1040EZ line; IRS Form 1040A line 27) ___ $14,700 or less ___ $24,901 - $30,000 ___ $40,201 - $45,300 ___ $14,701 - $19,800 ___ $30,001 - $35,100 ___ $45,301 - $50,400 ___ $19,801 - $24,900 ___ $35,101 - $40,200 ___ $50,401 or more Complete below only if federal taxes WERE NOT filed: Federal regulations require that verification of family income must be submitted as part of the application/admission process for Upward Bound. If you were not required to file an income tax return for the last calendar year, you must complete this form and sign it. Source of Income Amount ___ Salary & Wages ___ Self-Employment Income ___ Social Security ___ Disability Income ___ Veterans Benefits ___ Child Support ___ Aid for Dependent Children (AFDC) ___ Food Stamps ___ Unemployment Insurance ___ Retirement ___ Other ______________________ $ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ Total Yearly Income $ ____________ I certify that the above income is accurate and correct to the best of my knowledge. I agree to provide any documents necessary to verify any information reported on this form. ________________________________ Parent/Guardian Signature ____________________ Date ________________________________ Parent/Guardian Signature ____________________ Date Upward Bound is 100% federally funded by a grant from the U.S. Department of Education Office of Post-secondary Education. Updated: June 11, 2014 INFORMACION DE INGRESOS (toda información es CONFIDENCIAL) Por favor de llenar si lleno impuestos este año: Clasificación: ___Soltero(a) ___Casado, lleno Junto ___Casado, lleno Separado ___Head of Household Total numero en hogar (exemptions): _______________ Confirme sus ingresos IMPONIBLE para el ano más reciente de impuestos. (FORMA IRS 1040 línea 43; FORMA IRS 1040A línea 27) ___ $14,700 o menos ___ $24,901 - $30,000 ___ $40,201 - $45,300 ___ $14,701 - $19,800 ___ $30,001 - $35,100 ___ $45,301- $50,400 ___ $19,801 - $24,900 ___ $35,101 - $40,200 ___ $50,401 o mas Por favor llenar abajo si usted no lleno impuestos este año: Las regulaciones Federales requieren esta verificación de ingresos de su familia. Debe ser entregada como una parte de la aplicación/proceso de admisión para el proyecto de Upward Bound. Por favor complete y firme esta forma. El origen de cantidad de sus ingresos Cantidad ____ Sueldo y Salario $ _____________ ____ Ingresos de Empleo Propetario _____________ ____ Ingresos de Seguro Social _____________ ____ Ingresos de Incapacidad _____________ ____ Ingresos de Beneficios de Veteranos _____________ ____ Ingresos de Beneficios de Social para Niños _____________ ____ Ingresos de Beneficios de AFDC Social _____________ ____ Estampillas para la comida _____________ ____ Ingresos de seguro de desempleo _____________ ____ Ingresos de sueldo de jubilación _____________ Total de Ingresos Añales $ _____________ Yo afirmó que la información de esta aplicación es cierta y según mi leal saber y entender esta bien. Estoy de acuerdo de proveer los documentos necesarios para probar la información reportada en esta forma. __________________________________ Firma de Padre/Guardian ___________________ Fecha __________________________________ Firma de Padre/Guardian __________________ Fecha Upward Bound is 100% federally funded by a grant from the U.S. Department of Education Office of Post-secondary Education. Updated: June 11, 2014 Student Name: _______________________ Student ID:_________________________ High School:________________________ Consent for Release of Academic Records I, hereby, give permission for Midland College Upward Bound program to obtain any and all of my academic records including high school Student Permanent Record and all future college transcripts and records. I understand that these records may contain identifying data, grade reports, high school and future college transcripts, test scores, immunization records, and teacher evaluations. Parent or student may examine a copy upon request. I understand that these records will only be used by the project on an individual basis. I also understand that compiled records on a group basis may include any and all of these records. Compiled information will be used to meet federal regulations of program evaluation. None of my identified, individual records will be released to any person, corporation, organization, nor present or future employer. ______________________________________ Student Signature _____________ Date ______________________________________ Parent Signature _____________ Date ______________________________________ Parent Signature _____________ Date Upward Bound is 100% federally funded by a grant from the U.S. Department of Education Office of Post-secondary Education. Updated: June 11, 2014 Student Name: _______________________ Student ID:_________________________ High School:________________________ Consentimiento para Librar los Archivos Academicos Yo, por esto doy permiso para Midland College Upward Bound que obtenga cualquier y todos mis archivos academicos incluyendo de secundaria registro permanente y cualquier y todos traslado de universidad futuro y archivos. Yo comprendo que estos archivos podria contener indentificar reportes de grado de datos, secundaria y traslados de universidad futuros, calificaciones, archivos de inmunizacion, y evaluaciones de profesores. Padres o estudiante podria examinar una copia sobre solicitud. Yo comprendo que estos archivos solamente seran usados por el proyecto en fundamento individual. Yo tambien comprendo que copile archivos en un fundamento de grupo puede incluir cualquier y todos de estos archivos. Informacion compilada sera usada para encontrar regulaciones federales de evaluacion de programas. Ninguno de mis archivos identificados, sera lanzado a cualquier persona corporacion, organizacion,o presente o futuro patron. ______________________________________ Firma del estudiante _____________ Fecha ______________________________________ Firma de padres o guardían _____________ Fecha ______________________________________ Firma de padres o guardían _____________ Fecha Upward Bound is 100% federally funded by a grant from the U.S. Department of Education Office of Post-secondary Education. Updated: June 11, 2014 Student Name: _______________________ Student ID:_________________________ High School:________________________ Counselor Evaluation (to be completed by student’s school counselor) The student named on this form is applying to the Upward Bound Program, a federally funded program from the US Department of Education to encourage first‐generation, limited‐income students to further their education. Your careful and complete assessment of the student will help us determine if the candidate will benefit from the Upward Bound Program. Your prompt response is greatly appreciated. Academic Potential □Yes □No Does the applicant have a desire and/or determination for academic success and/or achievement? □Yes □ No Does the applicant possess the academic potential to continue his/her education beyond high school? Academic Background □Yes □No □Yes □No □Yes □No □Yes □No Is the applicant “on track” to graduate with his/her class? Does the applicant have attendance problems? Has the applicant passed all applicable parts of the STAAR? If not please check which area(s) was/were not passed? Indicate N/A, if not taken. _____ Reading/Writing (8th) _____ English I (EOC) _____ English II (EOC) _____ Math (8th) _____ Algebra I (EOC) _____ Science (8th) _____ Biology (EOC) _____ Social Studies (8th) _____ U. S. History (EOC) Does this applicant have a discipline problem at school? (any office referrals?) Academic Need Please check all of the following which apply to the student: _______ Will need help with taking of College Entrance Exams _____ TSI _____ SAT _____ ACT ________ Will need help with college financial aid _______ Will need help with college applications _______ Needs tutoring/enhancement in at least one of the core subject areas. _______ Personal and/or family difficulties Upward Bound is 100% federally funded by a grant from the U.S. Department of Education Office of Post-secondary Education. Updated: June 11, 2014 Counselor Evaluation (continued) Please check up to 2 of the following: 01-Low high school grade point average 02-Low achievement test scores 03-Low educational aspirations 04-Low high school grade point average and low educational aspirations 05-Low high school grade point average and low achievement test scores 06-Low achievement test scores and low educational aspirations 07-Lack of opportunity, support, and/or guidance to take challenging college preparation courses 08-Lack of career goals and/or need for accurate information on careers 09-Limited proficiency in English 10-Lack of confidence, self esteem, and/or social skills 11-Predominately low income community 12-Rural isolation 13-Interest in career in math and science Academic Status of Applicant Current or most recent Grade Point Average: _________________ CALCULATE ON A 4.0 SCALE PLEASE!! Current ranking in class: _________________ of _________________________ Rank Total number in class Recommendation for participation □Strongly recommend □Recommend with reservation □Do not recommend Additional comments on applicant that may aid us in our selection process: ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ _________________________________ Counselor Signature _________________ Date Upward Bound is 100% federally funded by a grant from the U.S. Department of Education Office of Post-secondary Education. Updated: June 11, 2014