UPWARD BOUND PROGRAM Admissions Application

Transcription

1 UPWARD BOUND PROGRAM Admissions Application Name Current Grade Date A Federally Funded Program Paid for by the U.S. Department of Education and Passaic County Community College

2 Passaic County Community College UPWARD BOUND PROGRAM Application For Admission INSTRUCTIONS READ all information carefully before completing the application SUBMITTING YOUR APPLICATION: Your completed application should be returned to the Upward Bound Program accompanied by the following required documents: 1. An official Copy of your high school transcript 2. Three (3) recommendations from your Guidance Counselor, English and Math Teachers included on pages 6 & 7 of this admissions application 3. Complete the student Essay on page 8 of this application 4. A Copy of your Social Security Card/ or Alien registration card (front and back) 5. A Copy of your Parent/Guardian most recent Federal income Tax Return (1040, 1040A, or 1040 EZ) 6. For those who did not file an income tax return you must complete the Non-Income Tax filers income verification included on page 9 in this application. It must be notarized by a notary public. 7. PROOF of Aid for AFDC, Social Security, or Pension benefits. Social Security Number Your social security number is required for identification purposes only. It further serves to ensure the accuracy of our student admissions records. TITLE IX COMPLIANCE Passaic County Community College does not discriminate on the basis of race, color, national origin, religion, physical disability, age, sex, or sexual orientation. Incomplete Applications Applications that are submitted without the required documents are considered incomplete and cannot be processed until all of the required documents have been submitted. 2

3 Part I (please type or print clearly) Social Security Number Name Last First Middle Permanent Address Street City State Zip Code Home Telephone ( ) Date of Birth / / Sex: Male Female Ethnic Origin: African American, Non-Hispanic American Indian / Alaskan Native Asian or Pacific Islander Caribbean Islander Hispanic, Non-Puerto Rican Puerto Rican Other White, Non-Hispanic If you are a resident of New Jersey, how long have you lived in New Jersey? Are you a U.S. Citizen? YES NO Alien Registration Number Do you have any physical disabilities? YES NO If yes please explain Person to be notified in case of emergency: Name Last First Address Street City State Zip Code Relationship Home Phone Work Phone 3

4 Parent / Guardian Information Mothers Name Last First Middle Fathers Name Last First Middle Guardian Name _ Last First Middle With whom does the student live? Mother & Father Mother only Father only Grandparent Aunt Uncle Brother Sister Foster parent OTHER: Family Size How many Brothers / Sisters Others brothers sisters Name of Parent/Guardian living with you: Name of Employer: (Mother) Name of Employer: (Father) Employer Address: (Mother) Phone: Employer Address: (Father) Phone: Yearly Income (Mother) Yearly Income (Father) Total Income Status: $20,000 or less $20,000 to $29,999 $30,000 to $39, 999 $40,000 to $49,000 $50,000 to $59,000 Over $60,000 Level of Education of Father: Mother: Is the student employed: YES NO How many hours per week. Have either parent (Mother./ Father or Guardian) obtained a four year degree. YES NO Does student or either parent receive the following benefits: (Check any from the list below that apply) AFDC Social Security Benefits Pension Benefits OTHER Did applicants Parent (s) / or Guardian file an Income Tax Return for the tax year 2002 YES NO If you checked YES, remember to attach a copy. If you checked NO, complete page 9 and have it notarized. 4

5 Part II High School CEEEB Code Address Street City State Zip Code High School Phone Number ( ) Date of Graduation Guidance Counselor Guidance Counselor Phone Number ( ) Academic Program: (Check One) College Prep Vocational General Remedial Grade: ( ) Freshman ( ) Sophomore ( ) Junior Part III Clubs/Organizations: (check all that apply) Other Student Government Debate Drama Club Science Club Year Book Newspaper Math Club Art Club Civics Club Choir Band Other Activities you are involved in. Honors /Awards (please list) Athletics: Basketball Softball Football Baseball Track Volleyball Tennis Soccer / OTHER Have you participated in any other pre-college program? YES NO. If YES please check: Upward Bound Talent Search Gifted & Talented ASPIRA College Bound If other than those listed above, please list name and dates of participation: 5

6 Part IV Recommendation Forms (To be completed by Guidance Counselor, English and Math Teachers) ENGLISH TEACHER RECOMMENDATION Please rate the student in the following areas (1=lowest; 5= highest) Grasps fundamental ideas and concepts Integrates complex information Completes assignments; fulfills contracts Has good work habits; is disciplined Has a positive sense of self Is Motivated to achieve Accepts constructive criticism Shows potential for more advanced study Has a foundation in basic skills Assumes responsibility I have known this student for Comments Signature Date MATH TEACHER RECOMMENDATION Please rate the student in the following areas (1=lowest; 5= highest) Grasps fundamental ideas and concepts Integrates complex information Completes assignments; fulfills contracts Has good work habits; is disciplined Has a positive sense of self Is Motivated to achieve Accepts constructive criticism Shows potential for more advanced study Has a foundation in basic skills Assumes responsibility I have known this student for Comments Signature Date 6

7 GUIDANCE COUNSELOR RECOMMENDATION Please rate the student in the following areas (1=lowest; 5= highest) Grasps fundamental ideas and concepts Integrates complex information Completes assignments; fulfills contracts Has good work habits; is disciplined Has a positive sense of self Is Motivated to achieve Accepts constructive criticism Shows potential for more advanced study Has a foundation in basic skills Assumes responsibility OTHER List below the school programs student participates in ( example: Drop-out prevention, Teen Mothers, etc.). Please state briefly why you feel this student is a good candidate for the Upward Bound Program. Student Cumulative Grade Point Average: as of Date Student Test Scores: GEPA Math Verbal Science STAT 9 Math Verbal Science HSPA Math Verbal Science PSAT Math Verbal SAT Math Verbal I have known this student for Additional comments Signature Date 7

8 Part V STUDENT ESSAY How did you learn about the Passaic County Community College Upward Bound Program? Please write a 3-4 paragraph essay explaining why you are interested in participating in the Passaic County Community College Upward Bound Program, and why you should be selected. 8

9 Part VI Income Verification for Non-Income Tax Filers (Complete this section if you did not file a federal 1040 / 1040A / 1040EZ with the Internal Revenue Service) I (We) did not file / are not required to file a federal income tax return (U.S. or any other government). I (We) certify that all financial information on the Passaic County Community College Upward Bound Program application that will be used to calculate my child s eligibility for participation in this federally funded program is complete, accurate, and correct. Student s Name Social Security Number List Names and ages of everyone in the household: The bottom section of the application must be NOTARIZED by a licensed notary public. your application will not be processed without this section being notarized. Sources of Income Earned Weekly Amount Monthly Amount Yearly Amount SIGNATURE VERIFICATION Applicant Signature Date Mother/Female Guardian Signature Date Father/Male Guardian Signature Date Notary Public Signature and Seal Below Date NOTARY SEAL 9

10 Upward Bound Program Interview Notes Date of Interview: Staff Signature: For Office Use Only Grades Attached: YES NO Grade Point Average Test Scores: GEPA STAT 9 HSPA PSAT SAT Tax information YES NO Income Information YES NO NOTARY SEAL YES NO PROOF of Aid YES NO Soc. Sec. Card YES NO Alien Registration Card YES NO Action Taken: Accepted Wait List Rejected Provisional Acceptance Comments: 10