trio upward bound application
to be completed by the student
first name:
*
middle initial:
*
last name:
*
street address:
*
city:
*
state:
*
alabama
alaska
american samoa
arizona
arkansas
armed forces - americas
armed forces - europe/africa/canada
armed forces - pacific
california
colorado
connecticut
delaware
district of columbia
federated states of micronesia
florida
georgia
guam
hawaii
idaho
illinois
indiana
iowa
kansas
kentucky
louisiana
maine
marshall islands
maryland
massachusetts
michigan
minnesota
mississippi
missouri
montana
nebraska
nevada
new hampshire
new jersey
new mexico
new york
north carolina
north dakota
northern mariana islands
ohio
oklahoma
oregon
palau
pennsylvania
puerto rico
rhode island
south carolina
south dakota
tennessee
texas
utah
vermont
virgin islands
virginia
washington
west virginia
wisconsin
wyoming
postal code:
*
school:
*
current grade:
*
date of birth:
*
age:
*
gender:
*
home phone:
student's cell number:
*
student's email:
*
academic need (check all that apply):
*
do you currently have a job?:
*
where?:
*
how many hours in a week do you work:
*
ethnicity:
race:
i plan to go to college:
*
have you considered a college major?:
*
please indicate chosen major:
*
first and last names of parents or guardians that i live with:
*
current extracurricular activities:
*
electronic signature agreement: you agree your electronic signature is the legal equivalent of your manual signature on this application. you agree that your signature on this document is as valid as if you signed the document in writing.
student signature:
*
the following questions are to be completed by parent/guardian
(1) parent/guardian first name:
*
(1) parent/guardian last name:
*
relationship to child:
*
employer and/or occupation:
*
(2) parent/guardian first name:
authorized business phone number: *
(2) parent/guardian last name:
relationship to child:
employer and/or occupation:
marital status:
*
total number of people in your household:
*
parent/guardian email:
*
phone/cell number:
*
father graduate from a 4-year college or university?:
*
name of college or university:
*
mother graduate from a 4-year college or university?:
*
name of college or university:
*
child's name:
*
student is currently in foster care or legal ward of state?:
*
is your child a u.s.. citizen?:
*
permanent resident card # uscis (after your application has been processed, we may request a copy of the permanent resident card):
*
the upward bound program offers services to assist students who have the potential to succeed in higher education. the program hosts:
weekly academic assistance at emmetsburg, estherville and spencer iowa lakes community college campuses.
College Campus Visits & Cultural events staffed at a 1:10 ratio (1 adult for every 10 students)
Workshops and Curriculum on the following topics: Study Skills, Goal Setting, Career Decision Making, Rigorous Course Scheduling, Choosing a College, The College application Process, ACT registration & Prep, Writing a Scholarship Essay, and fafsa completion.
free online tutoring and career exploration.
my child could participate fully in all upward bound services listed above:
*
i believe my student will:
*
taxable income amount (this is not your gross income but your income minus any deductions or exemptions allowed in the tax year. ) it can be found on your form 1040 (line 11b), 1040a (line 27), or 1040 ez (line 6).
taxable income amount:
*
if you did not file a federal income tax return last year, please check all of the following that apply:
*
tanf or fip #:
*
do you have other children in grades 9-12 that would like to apply for trio upward bound ?
name:
school:
grade:
electronic signature agreement: you agree your electronic signature is the legal equivalent of your manual signature on this application. you agree that your signature on this document is as valid as if you signed the document in writing.
parent signature:
*
by hitting the submit button, i agree to the following:
trio upward bound release of information
i acknowledge that iowa lakes community college trio upward bound program’s purpose is to prepare me to successfully graduate from high school and a college or university. as a federally-funded program, upward bound must abide by the u.s. department of education’s rules and regulations in regards to tracking current and former trio upward bound students [authorization: u.s. department of education:
therefore, i hereby authorize for all high-school and post-secondary documentation to be released to the iowa lakes community college trio upward bound program.
i am signing this release form with the knowledge that this document is valid for the next ten (10) years for the purpose of tracking academic information.
i also give consent for the iowa lakes trio upward bound program to transport my student to all events sponsored by the program. additionally, i understand that my student may be photographed/video-taped while participating in program activities and i agree that photographs/videos may be used in various social media to promote the program to other students, parents and institutions.
grip-e-hp
