Upward Bound Program Application (Parent Information Form)

To be completed by the Student's Parents.

Upward Bound is a federally funded academic college preparatory program for high school students that that is designed to help students overcome the academic, financial, and personal barriers to get into and succeed in college. We serve a very limited number of students and are requesting your information for your child to be considered for the program. Completion of this form does not guarantee acceptance into the program.

Student Information
Student's Name Student's Name First Last
Last four digits of Student's Social Security Number
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Student Phone Number Student Phone Number - ### - ### ####
Is your child a US Citizen?

Is your child a US Citizen? Yes No
If no, is he/she a legal resident?

If no, is he/she a legal resident? Yes No
Parents/Guardians Information (that student lives with)

Parent/Guardian #1
Name Name First Last
Email
Home Phone Home Phone - ### - ### ####
Cell Phone Cell Phone - ### - ### ####
Occupation
Employer
Relationship to Student

Relationship to Student Birth Parent Step Parent Foster Parent Grandparent Other Other
Highest Level of Education Completed

Highest Level of Education Completed Some High School GED High School Diploma Certificate Associate's Degree Bachelor's Degree Master's Degree Doctorate Degree Post Doctorate
Parent/Guardian #2
Name Name First Last
Email
Home Phone Home Phone - ### - ### ####
Cell Phone Cell Phone - ### - ### ####
Occupation
Employer
Relationship to Student

Relationship to Student Birth Parent Step Parent Foster Parent Grandparent Other Other
Highest Level of Education Completed

Highest Level of Education Completed Some High School GED High School Diploma Certificate Associate's Degree Bachelor's Degree Master's Degree Doctorate Degree Post Doctorate
Please check the box of the forms of income that you currently receive each month

Please check the box of the forms of income that you currently receive each month Work Income Unemployment Income Disability Income Social Security Income Retirement Income TANF
Are you required to file taxes?

Are you required to file taxes? Yes No
What is your Household TAXABLE Income per year?

Taxable income is NOT the same as GROSS income or total annual income and is usually lower; this number DOES impact student eligibility for the program. This is found on your tax return, listed as TAXABLE INCOME.

Found on IRS Forms: Form 1040-Line 43 on; Form 1040EZ-Line6; Form 1040A-Line 27
Number of People Living in the Household (including yourself)
I certify that all information provided in this Upward Bound Program Application is accurate and true. I understand that I may be asked by the Upward Bound Program Manager for a copy of my income statements.
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY

Upward Bound Program Application (Parent Information Form)

Upward Bound Program Application (Parent Information Form)

Student Information

Parents/Guardians Information (that student lives with)

I certify that all information provided in this Upward Bound Program Application is accurate and true. I understand that I may be asked by the Upward Bound Program Manager for a copy of my income statements.