Rhode Island College UPWARD BOUND PROGRAM IMPORTANT INFORMATION FOR 2018 APPLICANTS APPLICATION DEADLINE: Friday, November 30, 2018

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1 Rhode Island College UPWARD BOUND PROGRAM IMPORTANT INFORMATION FOR 2018 APPLICANTS APPLICATION DEADLINE: Friday, November 30, 2018 Applications will be available in the guidance office of each high school and on the Upward Bound website. To complete the application process, applicants should follow the checklist below. Applicants should complete form, print form, obtain signatures, attach materials and submit to guidance office. Checklist to Complete Application: Discuss Upward Bound s commitment and expectations with your parents/guardians and obtain permission to apply. Complete the Student Application form. Be sure to submit the required essay. Provide a copy of your Social Security card AND one of the following: o U.S. birth certificate o Puerto Rican birth certificate (issued after July 2010) o U.S. Certificate of Citizenship document or Naturalization (form N-550 or N both sides) o U.S. passport o Permanent Resident Card (I-551 or I-94) o Any other document that proves your intent to become a permanent resident Complete and have the Parent/guardian sign the Release/Permission Form. Staple to the application one of the following for income verification (provide the documentation for all parents/ guardians living in the home with the applicant): o Copy of your parents 2017 Federal Income Tax Forms (pages 1 and 2 of the 1040 Form -- do NOT provide W-2 forms as they are not needed see reverse side of page for sample of forms) o Official documentation verifying that you and/or your family are on public assistance with benefit amount o Official documentation from the Social Security or Veteran s Administration, with benefit summary. Student and Parent/Guardian Signatures make sure to sign the application in both required sections. Package your application, family information, copies of required documents and essay. Submit all materials to your guidance counselor by Friday, November 30, Be sure to provide signatures of the applicant and his/her parent/guardian. Keep the program brochure for your future reference. All application materials and high school transcripts will be reviewed. Eligible students and a parent will be scheduled for a private interview at the high school. Important Dates for Students Selected for Admission: First Academic Year (tentative spring 2019 dates): Week of February 25: Welcoming session for new students will be held in each high school. Saturday, March 2: An orientation and induction ceremony for students and their families will be held on RIC s campus. March 9 May 4: Saturday Academy classes are held during the first semester Summer Residential/Academic Program: The schedule for the summer component will be provided to participants and families in early March. Until then, students and families should plan to be available during the period from Sunday, June 16 to Friday, August 2, See reverse side of this form for a helpful guide of required forms (samples)! If you have any questions, contact the Upward Bound office. Office hours: Monday-Friday, 8:30am-4:30pm. Upward Bound Program, Building #6, Lower Level, Rhode Island College Phone: (401) upwardbound@ric.edu Website: Facebook: RIC Upward Bound

2 Sample Guide for Required Forms Income Verification Samples: Sample of Federal Tax Form 1040 (1040A and 1040EX are similar) Sample of a statement from Social Security Administration (page 1 and 2) Citizenship Status Document Samples: U.S. Passport U.S. Certificate of Naturalization Permanent Resident Card (both sides needed) U.S. Certificate of Citizenship Form I-94 (paper or electronic version)

3 Rhode Island College UPWARD BOUND PROGRAM STUDENT APPLICATION FORM 2018 APPLICATION DEADLINE: Friday, November 30, 2018 Please complete ALL sections and answer EVERY question before submitting the application. Federal regulations require Upward Bound to collect this data to determine if the applicant qualifies for this federally funded program. Please write N/A if a question does not apply to you. STUDENT APPLICANT INFORMATION LEGAL NAME: Gender: First/Middle/Last Name (exactly as it appears on your Social Security card) U.S. Social Security #: DOB: Home/Mailing Address (Number and street name): Floor # or Apartment #: City: State: Zip Code: Home telephone #: Student s Cell Phone #: Student s Address: Student s Birthplace: Total # of years student has lived inside the U.S.: Total # of years student has lived outside the U.S.: U.S. Citizenship Status (check one) and provide copies of official government documentation: Student is a U.S. citizen or national Student is a permanent resident Student is in the U.S. for other than a temporary purpose (i.e. I-94). Verification must be provided from United States Citizenship and Immigration Services Other - Explain: Language Proficiency: What is your primary language? What language(s) are spoken in your home? Ethnicity: (this information is used for statistical purposes only and not to make admission decisions): Are you Hispanic/Latino? Yes, I am Hispanic/Latino. Please describe your origin(s): No, I am not Hispanic/Latino. Regardless of your answer to the previous question, please indicate how you identify yourself. Check all that apply and describe your origin on the line provided: Race: American Indian or Alaska Native (including North, South & Central America): Asian (including Indian subcontinent and Philippines): Black or African American (including Africa and Caribbean): Native Hawaiian or Other Pacific Islander (Original Peoples): White (including Middle Eastern): Other. Please be specific: Go to next page

4 Education: Name of High School: Grade: List all other schools you have attended since the 8 th grade, including summer school: School Names & location: Dates attended: List any academic distinctions or honors you have received since 8 th grade. Attach a separate sheet if more space is needed. When? When? When? Extracurricular Activities and Work Experience List your extracurricular, volunteer and work activities. Attach a separate sheet if more space is needed. When? When? When? Have you applied to the Upward Bound Program previously? Yes No If yes, when? Did any of your immediate relatives participate in the RIC Upward Bound Program? Yes No If yes, who? Relationship to you? Are you currently participating in other college preparatory or educational support programs? Check all that apply: The College Crusade/Gear UP Date started: Are you still enrolled? Yes No Educational Talent Search (ETS) Date started: Are you still enrolled? Yes No Breakthrough Providence Date started: Are you still enrolled? Yes No College Visions Date started: Are you still enrolled? Yes No Other (please specify) Date started: Are you still enrolled? Yes No List your career interests? REQUIRED ESSAY: Applicant must write an essay on the topic below and attach it to your application. Your essay must be between 300 to 500 words and at least 3 paragraphs. Prepare your essay using a computer. ESSAY TOPIC: Upward Bound is a very diverse community that recognizes individual differences and academic potential. Please reflect on your strengths, skills, and areas that need further improvement. Share with us what makes you unique, your interests, and your educational and career aspirations. How will Upward Bound help you? Go to next page

5 Rhode Island College UPWARD BOUND PROGRAM FAMILY INFORMATION FORM 2018 APPLICATION DEADLINE: Friday, November 30, 2018 The parent/legal guardian should complete this part of the form, and provide requested information for parents, even if one or more is deceased or no longer has legal responsibilities toward student. Please complete all sections and answer every question before submitting the application. Federal regulations require Upward Bound to collect this data to determine if the applicant qualifies for this federal funded program. Please write N/A if a question does not apply to you or the applicant. Name of student applying for admission: Name of parent/guardian completing this form: Household Information: APPLICANT S FAMILY INFORMATION Biological/Adoptive Parents marital status: Married (date: ) Never Married Widowed Separated (date: ) (in relation to each other) Civil Union/Domestic Partners Divorced (date: ) With whom does the Student Live? Check any that apply: Mother and Father Legal Guardian (provide legal documentation) Mother Only Dual Custody Father Only Ward of the State Mother and Stepfather Foster Parent Father and Stepmother Other Explain: Mother or Female Guardian Information: Is mother living? Yes No (date deceased: ) Mother/Female Guardian s Full Name: If Guardian, state relationship: Mother/Female Guardian s address: Apt. #: City: State Zip Code: Home phone #: Cell Phone: Address: Primary language: Highest degree earned: Less than high school Bachelor s Degree High school diploma Master s Degree Associates degree Doctorate School where earned: Date obtained: Place of employment: Occupation: Go to next page:

6 Father or Male Guardian Information: Is father living? Yes No (date deceased: ) Father/Male Guardian s Full Name: If Guardian, state relationship: Father/Male Guardian s address: Apt. #: City: State Zip Code: Home phone #: Cell Phone: Address: Primary language: Highest degree earned: Less than high school Bachelor s Degree High school diploma Master s Degree Associates degree Doctorate School where earned: Date obtained: Place of employment: Occupation: Parent/ Guardian: A response is needed for each question below. (This information is only used to better assist student and not for admission purposes). Does the applicant have a documented learning, medical or physical disability? Yes No If yes, check off which apply and offer a brief explanation if special accommodations are required: IEP or 504 Plan Yes No If yes, explain: Other learning disability, including attention disorders? Yes Medical condition/chronic disease? Physical disability? No If yes, explain: Yes No If yes, explain: Yes No If yes, explain: Other? Explain: Is applicant taking any prescribed medications? Yes No If yes, please list all medications: INCOME VERIFICATION & HOUSEHOLD INFORMATION FOR PARENTS/GUARDIANS The Department of Education provides funding for the Upward Bound Program based on specific eligibility requirements. To be considered for participation, the parents/guardians of all applicants must provide copies of their 2017 federal tax forms or a copy of their public assistance statement, or other official verification of income. NOTE: W2 FORMS AND PAY STUBS ARE NOT ACCEPTABLE FORMS OF VERIFICATION OF INCOME. Go to next page:

7 List full name of each person living in your household, including the applicant and all siblings who are listed as dependents as well as adults. If more space is needed, use a separate sheet of paper. 1. Student: Age: 2. Name: Age: Relationship to student: 3. Name: Age: Relationship to student: 4. Name: Age: Relationship to student: 5. Name: Age: Relationship to student: 6. Name: Age: Relationship to student: Federal Income Tax Filing Information for 2017 Did you file a 2017 U.S. Income Tax Return? Yes If yes, check your tax return filing status: Married, filing jointly Married, filing separately Single Head of household Qualifying widower No If you did not file, explain why not: Other source of income (check all that apply): Social Security Disability Retirement Public Assistance Other Explain: Federal Income Verification ATTACH ALL REQUIRED DOCUMENTS Check off ( ) which document you have attached to the application to verify your financial status for 2017 tax year: I have attached a copy of my 2017 federal tax forms (1040, 1040A, 1040EZ) for all parents/ guardians/ stepparents that live in the same household. (do NOT attach W2 or state tax forms). I have attached a copy of official documentation from Social Security or Veterans Affairs, with benefit summary for I have attached official documentation (letter from Social Worker or computer printout) to verify that the family receives public assistance (e.g. RIW, SNAP benefits). Has there been a change to the family s financial situation since January 2018? (for example, parent has become unemployed or disabled). If yes, please explain: CERTIFICATION (signatures are required for both applicant and parent(s)/guardian(s) providing information) I hereby certify that all statements in this application are true to be best of my knowledge and understanding. Any misleading information may be cause for immediate rejection of the application or dismissal from the program. Student Signature: Date: Parent/Guardian Signature: Date: Parent/Guardian Signature: Date: Go to signature page:

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9 Rhode Island College UPWARD BOUND PROGRAM RELEASE/PERMISSION FORM 2018 APPLICATION DEADLINE: Friday, November 30, ) I grant permission to the high school to issue, as requested and for as long as requested, all information, including grades, transcripts, state testing results and school medical records, to the Upward Bound Program. I understand that this information is needed and is for the exclusive use of the Upward Bound Program. 2) I grant permission to the Upward Bound Program to obtain information relevant to reports that the project must submit to its funding agencies, even if the student does not graduate from the program. This information includes financial aid awards and academic transcripts for each semester that the student is enrolled in college for a period up to 10 years. 3) I hereby grant to the Rhode Island College Upward Bound Program the right to reproduce, use, exhibit, display, broadcast, distribute and create using photographs or videotaped images of the undersigned person for use in promoting, publicizing or explaining the college or its activities. This grant includes without limitation the right to publish such images in the college PR/promotional materials, such as marketing and admissions publications, advertisements, fundraising materials and any other program-related publication. These images may appear in any of the wide variety of formats and media, including social media, now available to the college and that may be available in the future, including but not limited to print, broadcast, videotape, and electronic/online/social media. 4) If accepted, I grant permission for the student to receive all services from the Upward Bound Program including, but not limited to, meeting with the Program Counselors and staff for personal and academic advising in the high schools or at the Program offices. By signing below, permission is granted for all of the above. Printed Student Name: Date: Student Signature: Date: Printed Parent/Guardian Name: Date: Parent/Guardian Signature: Date: Printed Parent/Guardian Name: Date: Parent/Guardian Signature: Date: