Gateway Community College-UB

Upward Bound Program

A College Preparatory Program

Student Application
Student Name*

First NameMiddle NameLast Name
High School Name*

Upward Bound Information

What is Upward Bound?

Upward Bound is a FREE program funded by the U.S. Department of Education that offers academic, personal, and social support to high school students through their entrance into postsecondary education. Upward Bound is a motivational and academically based program assisting students with high school graduation and preparing students for enrollment and completion of postsecondary education.

Benefits of Upward Bound?

Receive stipends (get paid) during the academic year (up to $40 per month) and summer program (up to $60)
Receive mentoring with an academic advisor
Attend career exploration and personal enrichment workshops
Explore career opportunities through interactive programs
Participate in fun cultural, social, and career-oriented field trips
Receive after-school tutoring and mentoring sessions twice a week
Improve academic skills by attending classes in math, science, English, foreign language, computer skills, and study skills during the 6-week summer program at GateWay Community College
Assistance with college entrance requirements
Become informed on financial aid and scholarship opportunities
Creation of Individual Educational Success Plan
Meet new friends!

Some Examples of Personal Enrichment Sessions

Team Building	Job Readiness	Life Skills
Personal Wellness	Leadership	Career Development
Study Skills	Financial Literacy	Scholarship Search
Time Management	Interviewing	College Planning

*And many more educational oriented workshops

Who Can Participate?

Students attending North High School or Camelback High School
Has a need for academic support in high school and has the potential for academic success in postsecondary education
Must be a first-generation college student (parent/guardian has not attained a four-year college degree) AND/OR
Meet income eligibility requirements (defined by Federal Government Standards)
Be between the ages of 13-19
Be a Citizen or Permanent Resident of the United States

Application Checklist

Complete the Student Application form and sign
Complete the Student Personal Statement
Have your parent/guardian Complete and Sign the Parent/Guardian Application and Assurances Form
Attach a SIGNED copy of Parent/Guardian 20XX Federal Income Tax Forms from the previous year (1040, 1040EZ, or 1040A)
If your parent/guardian did not file an Income Tax Statement in the previous year, please complete and sign the Report of Family Income section on the Parent Assurances Section

NORTH High Students: Please direct any questions to Mr. Farrugia in the Counseling Office.
CAMELBACK High Students: Please direct any questions to Mrs. Badalamente in the Counseling Office.

Application Checklist
- Complete the Student Application form and sign
- Complete the Student Personal Statement
- Have your parent/guardian Complete and Sign the Parent/Guardian Application and Assurances Form
- Attach a SIGNED copy of Parent/Guardian 2019 Federal Income Tax Forms (1040, 1040EZ, or 1040A)
- If your parent/guardian did not file an Income Tax Statement in 2019, please complete and sign the Report of Family Income section on the Parent Assurances Section

High School Information
Current year in school*

9101112
Student Number*
School Counselor Name*

First NameLast Name
Please list any extra curricular activities you are involved with*
If you have attended any other high school, please provide information below
school name, city, state, & grades attended
Please provide the name of the Middle School/Junior High you attended *
school name, city, state, & grades attended
Please list, in order, the careers or occupation you are most interested in*
Please list, in order, the colleges, universities or technical schools you may be interested in attending*

Release of Educational Information
If selected, I authorize the Upward Bound Program to obtain school documents relative to and consistent with my education while enrolled in high school and college. Such documents may include, but is not limited to: official transcripts, progress reports, grade point average, class ranking, standardized test scores including AIMS, AzMERIT, ACT/SAT scores, class schedules, school lunch program eligibility, attendance, college enrollment & persistence and any other information used to determine academic, career, or college enrollment and progress.

I certify that all statements contained in this application are true and correct.
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy

Personal Statement
Upward Bound would like to know more about you. Please tell us in at least 200 words what makes you unique, what responsibility means to you, your long-term and short-term goals, and what you hope to gain from being a participant in the Upward Bound program. *

Parent/Guardian Application
Student Name*

First NameMiddle NameLast Name
Dear Parent/Guardian:

If you dream of a college education for your high school student, we’d like to help. The Upward Bound Program at GateWay Community College is a FREE program funded by the United States Department of Education. Our purpose is to motivate students to succeed and graduate from high school, enroll in college, and complete a postsecondary education of their choice. Our Upward Bound Program will serve a total of 67 students from North & Camelback High Schools in a variety of ways. We will be assisting your student improve their academic skills through tutoring after school twice a week, one day of which is mandatory. We will also help your student improve personal skills through workshops such as study skills, time management, career exploration, job readiness skills, and individual high school success plans.

The Upward Bound program is federally funded and it is required that a majority of the participants meet guidelines set forth by the Department of Education. Participants must meet certain income guidelines AND/OR be potential first-generation college students. For this reason, we are asking you to provide information on the following “Parent/ Guardian Application Form” regarding educational level and household income. We are also asking you to attach a SIGNED copy of your 20XX Federal Income Tax returns. This information will be kept confidential and will only be used for student selection and statistical documentation, as required by the U.S. Department of Education.

GateWay Community College’s Upward Bound program is working cooperatively with your student’s high school. In order to better assist students, it is important that our program staff have access to school records to determine your student’s academic needs and to develop plans to meet those needs. Your signature on the “Release of Information” portion of the form will allow our staff access to school records. Once again, this information will remain strictly confidential.

If you have any questions regarding this program or the requested information, please feel free to contact us at (602) 286-8677 or email elena.parker@gatewaycc.edu.

Sincerely,

Upward Bound Staff

What is Upward Bound?

Benefits of Upward Bound?

Receive stipends (get paid) during the academic year (up to $40 per month) and summer program (up to $60)
Receive mentoring with an academic advisor
Attend career exploration and personal enrichment workshops
Explore career opportunities through interactive programs
Participate in fun cultural, social, and career-oriented field trips
Receive after-school tutoring and mentoring sessions twice a week
Improve academic skills by attending classes in math, science, English, foreign language, computer skills, and study skills during the 6-week summer program at GateWay Community College
Assistance with college entrance requirements
Become informed on financial aid and scholarship opportunities
Creation of Individual Educational Success Plan
Meet new friends!

Some Examples of Personal Enrichment Sessions

Team Building	Job Readiness	Life Skills
Personal Wellness	Scholarship Search	College Planning
Study Skills	Financial Literacy	Leadership
Time Management	Interviewing	Career Development

*And many more educational oriented workshops

Who Can Participate?

Students attending North High School or Camelback High School
Has a need for academic support in high school and has the potential for academic success in postsecondary education
Must be a first-generation college student (parent/guardian has not attained a four-year college degree) AND/OR
Meet income eligibility requirements (defined by Federal Government Standards)
Be between the ages of 13-19
Be a Citizen or Permanent Resident of the United States

Citizenship
Please respond to the categories Regarding YOUR Student (check one box per question):
Is YOUR STUDENT a Citizen of the United States?*

YesNoPermanent Resident
If you answered “NO” to the question above, please complete:

I certify that I have been living in the United States since (month) _________ (year) _______ and that I am in the United States with intention of becoming a permanent resident
Month
Year
Please attach documentation from the U.S. Immigration and Naturalization Service to this application.

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Income Information
Did you file LAST YEARS' income taxes (20XX)?*

YesNo
A) If you FILEDTAXES last year, Please attach a copy of the first and second pages of your SIGNED 20XX Tax Return (IRS form 1040, 1040EZ,or 1040A from last year) and SIGN bottom of this page*

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If no, please fill out the following information.
B) If you DID NOT FILE LAST YEARS'TAXES, fill out this section and then SIGN bottom of this page:

I (we) _____________________________ did not and will not file a Federal Income Tax Return, IRS form 1040, 1040EZ, or 1040A for 20XX for the reason(s) checked below:

In 20XX, my family received $______________ each month from (check all that apply):

-Child Support -Federal Agency -Company
-State Agency - Other
I (we) _____first and last name_____ did not...*

First NameLast Name
My family received $__________ each month *
$____________
Money received from (check all that apply)*

Child SupportFederal AgencyCompanyState AgencyOther
Please specify Federal Agency, Company, or State Agency from above
TOTAL number in household (including parents and siblings)*
Parent/Guardian Signature (Parents/Guardians-ALL MUST SIGN HERE)*

Clear
Date*

MonthDayYear
mm-dd-yyyy

Release of Records
Permission to Participate
If selected, I authorize permission for my child to participate in the Upward Bound Program. This includes after school tutoring, personal mentoring, and enrichment workshops during the school year, attend off campus enrichment sessions, & participate in the 6-week summer program at GateWay Community College. I authorize Upward Bound staff to communicate (call, email, text) my student for educational purposes and logistical reasons during off campus field trips.*

YesNo
Release of Educational Information
If selected, this is to authorize permission for the Upward Bound Program to obtain school documents relative to and consistent with my Student’s education. Such documents may include, but is not limited to: official transcripts, progress reports, grade point average, class ranking, standardized test scores-ACT/SAT, AIMS, AzMERIT, class schedules, school lunch program eligibility, attendance, and any other information used to determine academic, career, or college enrollment and progress.*

YesNo
Media Release
This is to authorize permission for the Upward Bound Program to use photographs of my child for publications including, newsletters, brochures, or the GateWay Community College Upward Bound web site.*

YesNo
In case of emergency please contact (please provide information on two adults-relative/friend)
1) Name*

First NameLast Name
Relationship*
Address*

Street Address

Street Address Line 2

CityProvince

Zip Code
Home Phone*
(999)999-9999
Work Phone*
(999)999-9999
2) Name*

First NameLast Name
Relationship*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone*
(999)999-9999
I (we) certify that all statements above are true and correct
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Parent/Guardian Signature (optional second signature)*

Clear
Date*

MonthDayYear
mm-dd-yyyy

Informed Consent
Dear Parents/Guardians of Upward Bound Participants,

Your child is applying to participate in the GateWay Community College Upward Bound Program. We are required by the U.S Department of Education, which funds this project, to collect personal and academic information about your child which we use to monitor their educational progress, provide assistance, and to evaluate the effectiveness of our program.

We are required to inform you that:
- The agency funding this program, the U.S. Department of Education, requires that we provide personally identifiable information on all program participants annually.
- There are no more than minimal risks to your child.
- All information will be handled in a strictly confidential manner, so that no one will be able to identify your child when the results are recorded/reported.
- Your child's participation in Upward Bound is totally voluntary and you may withdraw at any time without negative consequences. If you wish to withdraw at any time, simply contact the Upward Bound office at 602-286-8677.
Please feel free to contact Elena Parker, Program Coordinator at 602-286-8677 or elena.parker@gatewaycc.edu if you have any questions about the Upward Bound Program.

I understand the program described above and have been given the opportunity to ask questions for clarification, as outlined above. I agree to allow my child/ward to participate with their assent when possible.
Print Name of Parent*

First NameLast Name
Date*

MonthDayYear
mm-dd-yyyy
Signature of Parent*

Clear
Date*

MonthDayYear
mm-dd-yyyy
ASSENT:

I understand my obligations as a participant of the Gateway Community College Upward Bound Project and I freely choose to take part in the program.
Print Name of Student*

First NameLast Name
Date*

MonthDayYear
Date
Signature of Student*

Clear
Date*

MonthDayYear
Date