Application For Admission. Mott Community College Upward Bound Program 1401 East Court Street Flint, MI

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Jeffery Wilkinson
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1 Application For Admission Mott Community College Upward Bound Program 1401 East Court Street Flint, MI

2 PERSONAL INFORMATION Please Print Clearly First Name: Address: Zip Code: Last Name: City: U.S. Citizen? Yes No Birth date: / / Gender: Male Female Month Day Year Phone: Alternate Phone: Racial/Ethnic Group: (Select all that apply) 1. Hispanic 2.American Indian/Alaskan Native 3.Asian 4.African-American 5. White 6.Hawai or Other Pacific Islander Current School: Grade: Counselor: Are you involved any other programs? Talent Search Gear UP BSIP COE Other: PARENTAL/GUARDIAN INFORMATION With whom does the student live? Both parents/adoptive parents Father/adoptive father only Mother/adoptive mother Legal Guardian(s) (please specify) Mother/Guardian Name: Address: Home Phone: Occupation: Work Phone: Highest of Education Level Reached: Elementary (K-8) High School (9-12) Some College Associate Degree Bachelor s Degree Graduate Degree Father/Guardian Name: Address: Home Phone: Occupation: Work Phone: Highest of Education Level Reached: Elementary (K-8) High School (9-12) Some College Associate Degree Bachelor s Degree Graduate Degree

3 Parental Income Statement Upward Bound is a program funded by the U.S. Department of Education. In order to insure that the MCC Upward Bound Program follows federal income guidelines we are asking you to fill out this form and provide income verification documentation with this application. 1. Name of Parent/Guardian Address of Parent/Guardian Total number in household: How many people live in your household (include children away at college)? Use your previous year tax return to complete the section below. Do not use the Adjusted Gross Income. If you did not file a tax return skip to Question #3. 2. Total taxable income: $ (Please Check the Tax Form used to file your taxes.) Form 1040 Form 1040A Form 1040EZ 3. If you did not file income tax, please state your source(s) of income: FIA Social Security: Child Support Pensions Workers Compensation Other: Parent s/guardian Signature Certifying Statement I certify that the information submitted in this application and any accompanying documentation is true to the best of my knowledge. I understand that falsification on my part may result in disciplinary action(s), including denial of admissions. I agree to comply with all the rules and regulations of the Mott Community College Upward Bound Program. Signature of Applicant Date Signature of Applicant s Parent/Guardian Date Application check list Complete application form accurately, including all signatures Have one of your teachers fill out teacher recommendation form. Turn all your material in to your school counselor/representative for a recommendation and transcript or a copy of your latest report card. Your counselor /school representative will deliver these to us. After application is received, qualified applicant will receive a letter to set up an interview with applicant and applicant s parent/guardian. We will process your application and notify you of our decision as soon as possible. For further information you may call (810) or visit our website Mott Community College is an equal opportunity institution and does not discriminate on basis of race, color; religion, national origin, sex, sexual orientation, political persuasion, age, weight, handicap, or martial status in any of its education programs and activities, including admission and employment. For more information, contact the Human Resources Office at (810) General Information

4 General Information What is Upward Bound? o Upward Bound is a college preparation program funded by the U.S. Department of Education designed to encourage students from low-income families and whose parents did not graduate from a four-year college to further their education beyond high school. Who is Eligible? o The Upward Bound staff selects 9 th and 10 th grade students based upon the recommendations of teachers, counselors, social service agencies and others who are acquainted with them. Upward Bound chooses those students with academic potential who need the opportunity to demonstrate their talent. Students must be attending or planning to attend one of the following High Schools: Southwestern, Northwestern, Beecher or Hamady. They also must be low income and/or first generation as defined by the Department of Education. How can it help me? o Upward Bound gives the high school student a chance to find out what college life is al about and helps the student develop those skills necessary to succeed in college. The program emphasizes reading, writing, math and science skills along with tutoring in the student s present curriculum. Personal, career and academic counseling are also provided. What do you do in Upward Bound? o During the summer, Upward Bound students attend classes at Mott Community College for six weeks and participate in a variety of academic, social and cultural activities, which include a 3-day college with dorm experience. During their regular school year, Upward Bound students are in contact with Upward Bound staff members including teachers, counselors and tutors through classes, home visits, counseling sessions and tutorials. Is there any cost involved? o Upward Bound students receive a monthly stipend for participation and all programs services are cost free to participants. More Information can be obtained by calling Upward Bound at (810) or on the web at FOR OFFICE USE ONLY Do not write in section below. Application Reviewed Yes Date: Applicant Interviewed: Yes No Applicant s Eligibility: FG/LI FG LI Applicant Interview Date: Academic needs: At-Risk: Acceptance Date: SS Card (Copy): Grade Level to Start: Rising 8 th 9th 10th Date of First Service: HS School Attending: Expected graduation Cohort: GPA: NCES: Counselor: LEP: Yes No Date of last service: Reason for leaving code: UB Coordinator Signature: UB Director Signature: Date: Date:

TEACHER S RECOMMENDATION This section must be completed by school teacher Student s Name: Please rate the above student according to the scale on the bottom of this sheet: Rating Attitude toward

5 TEACHER S RECOMMENDATION This section must be completed by school teacher Student s Name: Please rate the above student according to the scale on the bottom of this sheet: Rating Attitude toward school work Intellectual ability Initiative/motivation Integrity Influence and leadership ability Ability to get along with others Responsibility Emotional stability Attendance Scale for Rating: 4 Exceptional 3 Good 2 Average 1 Poor Comments: Teacher s Signature: School: Date:

California State University, Los Angeles TRIO Upward Bound & Upward Bound Math/Science

California State University, Los Angeles TRIO Upward Bound & Upward Bound Math/Science Application must be completed in black or blue ink only. STUDENT INFORMATION Name: Social Security # - - First Middle Last Address: Apt.# Phone: ( ) City: State: Zip Code: Date of Birth: Place of Birth: