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STUDENT APPLICATION PLEASE MAKE SURE THE FOLLOWING DOCUMENTS ARE ATTACHED TO
THE COMPLETED APPLICATION
A copy of your course schedule (this will be required at the beginning of each semester)
A copy of your current transcript (an unofficial copy is acceptable)
A copy of the CAASPP Report
A copy of your parent’s IRS TAX FORM or other documentation which verifies income or aid
(for example, AFDC or Social Security award letter)
A copy of alien registration card if not a U.S. citizen
A completed recommendation form, from a school official
A writing sample answering the following questions:
1. What are your educational and career goals and how would you use it to help your community?
2. How would you describe yourself?
MODESTO JUNIOR COLLEGE ˑ 435 College Avenue ˑ Modesto CA 95350 ˑ (209) 575-6743
Modesto Junior College
UPWARD BOUND Creating Leaders through Education
Page 1
Due Date: ______________
Modesto Junior CollegeUPWARD BOUND Confidential Student Application
Please provide the following information, which is important to the administration of the Upward Bound Program.
All answers are kept strictly confidential.
PRIVACY ACT STATEMENT: The personal information that you give to the Upward Bound Director is sent to the federal government (Department of
Education). This information is protected by the Privacy Act. 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 helps the
government measure your success. The U.S. Department of Education has the authority to gather such information to help make Upward Bound a better
program (20 USC 1231a).
PLEASE PRINT USING BLACK OR BLUE INK
NAME: _______________________________________________________________________________________________________
(LAST) (FIRST) (MIDDLE)
ADDRESS: _____________________________________________________________________________________________________ (CITY) (ZIP CODE)
PHONE NUMBER: ___________________________________________ MESSAGE # ________________________________________
BIRTHPLACE: __________________ SEX: MALE ______ FEMALE _____
SOCIAL SECURITY #: __________-___________-____________
AGE: ________ DATE OF BIRTH: / /
U.S. CITIZEN: YES NO
PERMANENT RESIDENT: YES NO ALIEN REGISTRATION #: A_____________________________________________
American Indian or Alaska Native Asian Black or African American Hispanic or Latino
Native Hawaiian or Other Pacific Islander White Other: _______________________________________
ARE YOU AN ORPHAN OR A WARD OF THE COURT? YES _____ NO _____
IF YES, GIVE NAME OF LEGAL GUARDIAN _______________________________________ PHONE NUMBER: _____________________
FAMILY INFORMATION:
NAME OF FATHER/STEPFATHER: ___________________________________________________________________________________
PRESENTLY EMPLOYED: YES ____ NO _____ HIGHEST YEAR IN SCHOOL/COLLEGE COMPLETED BY FATHER: ________________
NAME OF MOTHER/STEPMOTHER: _________________________________________________________________________________
PRESENTLY EMPLOYED: YES ____ NO _____ HIGHEST YEAR IN SCHOOL/COLLEGE COMPLETED BY MOTHER: _______________
SCHOOL CURRENTLY ATTENDING: ________________________________________ STUDENT I.D. #: __________________________
GRADE LEVEL: ____________________ E-MAIL ADDRESS: _____________________________________________________________
DO YOU HAVE A DISABILITY? YES NO EXPLAIN: ___________________________________________________________
ARE YOU IN A SPECIAL ED CLASS? YES NO DO YOU HAVE AN IEP ON FILE? YES NO
ARE YOU OF HISPANIC OR LATINO OR CHICANO DESCENT? YES ______ NO _______
ETHNIC GROUP: (PLEASE CHECK ONE)
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Modesto Junior College UPWARD BOUND
How many brothers or sisters have attended or are currently attending college? ________________________________________________
What Language is spoken at home by the majority of your family? ___________________________________________________________
Please List all persons related to applicant living at home (continue on reverse of last page if necessary):
Name: ________________________________________________ Relationship: ____________________________ Age: _________
Name: ________________________________________________ Relationship: ____________________________ Age: _________
Name: ________________________________________________ Relationship: ____________________________ Age: _________
Name: ________________________________________________ Relationship: ____________________________ Age: _________
Name: ________________________________________________ Relationship: ____________________________ Age: _________
Name: ________________________________________________ Relationship: ____________________________ Age: _________
Name: ________________________________________________ Relationship: ____________________________ Age: _________
Name: ________________________________________________ Relationship: ____________________________ Age: _________
Do you currently have a job? Yes ______ No ______ If yes, how many hours do you work a week? _________
At what times? _____________________________________________________________________________________________________
What extra-curricular activities do you participate in (i.e. sports, clubs, choir, etc.)? ______________________________________________
__________________________________________________________________________________________________________________
When do you meet? ________________________________________________________________________________________________
FINANCIAL INFORMATION: Upward Bound uses Taxable income to determine eligibility.
If the applicant’s parents filed an annual tax form, please complete the information in Section A.
If the applicant’s parents do not file an annual tax form, please complete Section B.
For Assistance please contact: (209) 575-6743.
SECTION A: FOR FAMILIES THAT FILE ANNUAL TAX FORMS
FINANCIAL INFORMATION BASED ON THE ________________ IRS FORM 1040
(YEAR)
1) Adjusted Gross Income (1040: line 7) $_______________________
2) Total Standardized Deductions (1040: line 8) $_______________________
3) Subtract line 2 from line 1 above for NET TAXABLE INCOME= $_______________________
UB Revised 09/05/2019
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Modesto Junior College UPWARD BOUND
SECTION B: FOR FAMILIES THAT DO NOT FILE IRS TAX FORMS
1. INCOME FROM WORK:
If applicant’s family did not file a recent IRS TAX FORM, what was the parents’ annual income from work? $__________________
2. OTHER INCOME:
If applicant’s family receives other forms of income or assistance, please provide the monthly amount for each type of aid:
a. Social Security, Disability, Survivors Benefits $__________________
b. Temporary Assistance for Needy Families (TANF) $__________________
c. Unemployment Benefits $__________________
d. Other, please specify: ____________________________________ $__________________
3. TOTAL MONTHLY INCOME $__________________
CERTIFICATION
I, THE UNDERSIGNED, DECLARE UNDER PENALTY OF PERJURY THAT ALL INFORMATION REPORTED IS TRUE TO THE BEST OF MY
KNOWLEDGE.
____________________________________________ ____________________________________ ____________________
Student’s Signature Student’s Name PRINTED Date
____________________________________________ ____________________________________ ____________________
Parent’s Signature Parent’s Name PRINTED Date
PLEASE MAKE SURE THE FOLLOWING DOCUMENTS ARE ATTACHED TO THE COMPLETED APPLICATION
A copy of your course schedule (this will be required at the beginning of each semester)
A copy of your current transcript (an unofficial copy is acceptable)
A copy of the STAR Report
A copy of your parent’s IRS TAX FORM or other documentation which verifies income or aid
(for example, AFDC or Social Security award letter)
A copy of alien registration card if not a U.S. citizen
A completed recommendation form, from a school official
A writing sample answering the following questions:
1. What are your educational and career goals and how would you use it to help your community?
2. How would you describe yourself?
Page 4
Modesto Junior College UPWARD BOUND
STUDENT SELF ASSESSMENT
NAME: _______________________________________________________ DATE: ____________________________________________
INSTRUCTIONS: To help the Upward Bound staff assess your needs and develop a plan of services for you, we need to know how you
perceive yourself. Please read through the following lists and indicate whether you feel you have a “high need”, “some need”, or “no need”
for help or improvement in that area.
ACADEMIC SKILLS HIGH NEED SOME NEED NO NEED
English and Writing Skills
Spelling
Grammar
Punctuation
Writing Organization
Essay Writing and Reports
Verbal Expression
Learning/Improving English
Reading Skills
Improving Vocabulary
Reading Speed
Comprehension/Understanding
Retention
Math Skills
Basic Arithmetic
Basic Algebra
Advanced Math
Learning and Study Skills
Time Management
Developing Good Study Habits
Study for and taking tests
Taking notes in class
Developing Library Skills
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Modesto Junior College UPWARD BOUND
PARENTAL/GUARDIAN PERMISSION FORM
________________________________________________________ _________________________________________________
STUDENT’S NAME SCHOOL
Initial: ______ ACCESS TO RECORDS PERMISSION
I hereby give the Upward Bound Program staff permission to have access to report cards, high school transcripts, test
results and other pertinent information for the purpose of assessment, educational planning and counseling.
I understand that this permission will be in effect throughout my son’s/daughter’s participation in the Upward Bound
Initial: _______ FIELD TRIP PERMISSION
I hereby give my permission to the Upward Bound Program staff to take my son/daughter on various field trips to
colleges, cultural educational and recreational centers. This permission is given for Upward Bound approved activities and
will be in effect as long as my son/daughter is in the Upward Bound Program.
MEDICAL CONSENT
Health Status: Does your child have any past or present problems or conditions, which we should know about? Yes ______ No ______
If yes, explain: _____________________________________________________________________________________________________
If your child allergic to any medications: Yes ______ No ______ If yes, explain: _______________________________________________
Name of Family Physician: _____________________________________________ Telephone __________________________________
Is the student covered by Health Insurance? Yes ______ No ______
If yes, please provided Name of insurer: _____________________________________________ Medical #: _________________________
Medical Emergency: In case of an emergency please contact Parent/Guardian: _________________________________________________
Telephone (day) ______________________________________ (evening) _______________________________________________
If parent/guardian is not available, please contact: ___________________________________ Relationship: _______________________
Telephone (day) ______________________________________ (evening) _______________________________________________
Please give name, address, and telephone number of a relative/friend who has been living in the Modesto area for at least five years:
__________________________________________________________________________________________________________________
Initial: _______ MEDICAL RELEASE:
I agree to indemnify and save and hold harmless Yosemite Community College District, Modesto Junior College, its offic-
ers, agents and employees from and against any and all claims and liabilities which may arise out of or result from or be in
any way connected directly or indirectly to the above agencies while participating in the Upward Bound Program. Also I
consent to emergency treatment of my son/daughter by the staff of Yosemite Community College District and/or by the
staff of an accredited hospital or clinic if this is deemed necessary by the Upward Bound staff. I understand I will be noti-
fied of illness as soon as possible.
Parent/Guardian Signature: ____________________________________________________ Date: ______________________________
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Initial: ________ MANDATED REPORTING
Most information shared between participants are Program Representatives is held completely confidential. Please be aware of the few exceptions. Information shared regarding abuse (physical, mental, or sexual) and/or intent to harm oneself or others must be reported to the appropriate individuals with in the school districts.
Modesto Junior College UPWARD BOUND
RECOMMENDATION FORM
_________________________________________________________ _______________________________________________
STUDENT’S NAME SCHOOL
INSTRUCTIONS FOR THE SCHOOL OFFICIAL (Counselor, Instructor, Administrator):
This identifies a potential college student who may benefit from the counseling and tutoring provided by the Upward Bound Program. It
does not commit the nominating agency to any legal responsibility or liability.
NAME: ____________________________________________________ DATE: __________________________________________
Counselor/Instructor
TITLE: ____________________________________________________ PHONE #: _______________________________________
Please complete the following items as accurately as possible. If your relationship with the applicant does not allow you to make an
evaluation of an item please indicate “N/A” or not applicable. Please understand that this document may be made available for inspection
at the student’s request, pursuant to the Family and Educational Rights and Privacy Act and related laws and regulations.
How long have you known the applicant? _________________Year(s). Under what circumstances? ________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Based on your knowledge of the applicant, check how you rate his/her academic skills and potential to succeed in college.
Outstanding Above Average Average
Needs
Improvement
Academic Achievement
Writing Skills
Reading Skills
Math Skills
Academic Potential
Check how you rate the applicant’s character and motivation.
Strongly Agree Agree Agree Somewhat Disagree
Has positive self image
Demonstrates leadership
Has intellectual curiosity
Is highly motivated
Is tolerant of minor disappointments
Has ability to interact with peers and adults
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Modesto Junior College UPWARD BOUND
What other qualities come to mind that best describes the applicant? _________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
To the best of your knowledge, does this applicant have a historically disadvantaged background (i.e. low-income for several years, first
generation college bound, inner city or migrant family)?
Yes _____ No ____ If yes, please explain: _______________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
If you were the applicant’s college teacher or advisor, what services or assistance would you provide to help him/her succeed in college?
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Are you aware of any current circumstance or problems, which might affect the applicant’s performance in college (i.e. financial back-
ground, family responsibilities, educational preparation, health)?
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
What is your assessment of the student’s potential and motivation to succeed in college? What is your evaluation of the applicant’s capabil-
ity for undertaking college work?
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________ ___________________________________
Signature Date
NOTE: Please return this form to the applicant in a sealed envelope with your signature across the seal.
Page 8
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