Mohawk Valley Community College-UB

Oneida County
UPWARD BOUND PROGRAM
Mohawk Valley Community College

1101 Sherman Drive, Academic Bldg, Room #130, Utica, NY 13501
Phone(s): 315-731-5827 or 315-731-5836 Fax: 315-731-5891

Sponsored by U.S. Department of Education and Mohawk Valley Community College

To the applicant: It is essential that the entire application be completed before it is returned. An incomplete application will not be processed.

Mandatory Financial Information
In order to be considered a participant in the Upward Bound Program, the student’s parent/guardian must meet U.S. Department of Education income guidelines.
Student receives free/reduced lunch:*

YesNo
Parent/Guardian receives Social Security or other Social Services:*

YesNo
Number of people in household*
Total Income for last year ($)*
Please provide copies of social security or social services benefits letter*

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Parent/Guardian employed:*

YesNo
Number of people in household*
Taxable income for last year (from IRS form 1040 (line 40) or 1040A (line 27) ($)*
Please provide copy of IRS Tax form to verify taxable income*

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Cancelof
Student/Parent Commitment & Penalties for Misrepresentation:

MVCC’s Upward Bound Program requires students to attend weekly tutoring Monday through Thursday, academic classes on designated Saturday’s, and a six week Summer College on the MVCC campus. Students are also expected to attend cultural events and participate in community service as part of their participation in the program. Additionally, an acceptable record of attendance and behavior in Upward Bound and Proctor High School, as well as a GPA that reflects good academic standing, are program requirements. Failure to meet these program rules and requirements can exclude students from field trips, social events, and may result in dismissal from the program. Program rules and regulations are in our student handbook, which is given to all new students and is available in our office.

I also certify that all the above information is true, correct and current. I understand that this information is given in receipt of federal funds; that Upward Bound and TRIO program officials may verify the information on this application form and that deliberate misrepresentation of information may subject me to prosecution under State and Federal Laws.
Parent/Guardian Signature*

Clear
Date Signed

MonthDayYear
mm-dd-yyyy
Student Signature*

Clear
Date Signed

MonthDayYear
mm-dd-yyyy

Essay
Select ONE of the following essays and write in the box given below:*

1) Identify your most important dream and discuss how you plan to turn it into reality.2) What do you expect from the Upward Bound Program?
Please place essay in the box provided: (Minimum 250 words)*

0/1000
PRIVACY ACT STATEMENT

The personal information provided to Upward Bound is sent to the United States Department of Education and 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. This information is necessary to determine if you are eligible to participate in the program and helps the government to measure your success. The United States Department of Education has the authority to gather information to help make Upward Bound a better program (20USC1231a).

The Upward Bound Program at Mohawk Valley Community College is funded by the United States Department of Education and Mohawk Valley Community College. Participation is available to eligible students without regard to race, color, national origin, age, sex or handicap. Any person who believes that he or she has been discriminated against in any related activity should write to the Secretary of Education, Washington, D.C. 20250.

Parental/Guardian Consent/Release Form
This consent form authorizes your son/daughter to be given medical treatment and fully participate in all events/activities that Upward Bound provides. Please initial the areas of consent that you are in full agreement with. Please return this form to the Upward Bound Staff.
(1) I CONSENT to the treatment of my son/daughter by the medical staff of Mohawk Valley Community College, local hospitals, immediate care facilities and practicing physicians and/or surgeons in case of an illness and/or accident for the period of time he/she is participating in the Upward Bound Program.*

YesNo
Please Initial:*
Place initials here
(2) I GIVE PERMISSION for my son/daughter to go on planned trips and to be driven by a competent licensed adult to and from events/activities. I understand that Mohawk Valley Community College has made no representation concerning the safety of the methods of travel to and from or the travel sites visited.*

YesNo
Please Initial:*
Place initials here
(3) I GIVE PERMISSION for the release of my son’s/daughter’s school records, (ie: report cards, medical records, IEP’s, etc.) to the College Outreach/Upward Bound Program during his/her participation in the program and permit the release of this information to other programs/institutions as necessary.*

YesNo
Please Initial:*
Place initials here
(4) I GIVE PERMISSION for my son’s/daughter’s picture to be taken and used for College Outreach/Upward Bound newsletters, websites, and any other promotional ads that support our goals.*

YesNo
Please Initial:*
Place initials here
Student Name*

First NameLast Name
Parent/Guardian Signature*

Clear
Date Signed

MonthDayYear
mm-dd-yyyy
All information received will be held in strict confidence. This information is necessary to insure that the applicant meets the criteria for admission as established by the U.S. Department of Education.