Modesto Junior College UPWARD BOUND

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

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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: _________








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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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?

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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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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.


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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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.

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Documents

Modesto Junior College UPWARD BOUND