Northern Oklahoma College-UB

Northern Oklahoma College Enid

Upward Bound Academy Application

Student Information
Name*

First NameMILast Name
Social Security Number*
999-99-9999
Address*

Street Address

Street Address Line 2

CityState

Zip Code
E-mail Address*
example@example.com
Home Phone*
(999)999-9999
Student Cell Phone
(999)999-9999
Age*
Birth Date*

MonthDayYear
mm-dd-yyyy
Gender*

MaleFemaleOther
Ethnic Background*

American IndianAfrican-AmericanCaucasianAsianPacific IslanderHispanicOther
Are you a citizen of the United States?

YesNo
If no: Permanent Resident I.D. Number
*Please provide copy of immigration documents

Browse Files

Cancelof
Current School*
Current Grade Level*
Cumulative GPA*
School Counselor
My child _______ have a current IEP on file at his/her school

DoesDoes not

Family Information
Parent/Guardian*
Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code
Cell Phone Number*
(999)999-9999
Employer/Occupation
Work Phone Number
(999)999-9999
E-mail Address*
example@example.com
Spouse/Guardian
Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code
Cell Phone Number
(999)999-9999
Employer/Occupation
Work Phone Number
(999)999-9999
E-mail Address
example@example.com
Whom does the student live with?

Mother/FatherMotherFatherGuardianOther
Language(s) spoken in home
Does either parent have a 4-year college degree?*

YesNo
If yes, who?
Degree earned
Is anyone in your family receiving services from Upward Bound?

YesNo
If yes, who
Is anyone in your family receiving services from a Gear Up program?

YesNo

Financial Information
Number of adults in household (19 & older)
Number of children in household (ages 0-18)
What is your taxable income? (Found on page 2 of the most recent federal tax return)
Does anyone in your household receive the following? (Please check all that apply)*

Free or Reduced LunchUnemploymentVA BenefitsFood StampsDisabilitySocial SecurityRetirementOther

Statement Of Confidentiality
The information you provide in this application is confidential according to the Family Rights and Privacy Act. The U.S. Department of Education has the authority to gather the information requested in this application (20 USC 1231a). The only persons authorized to examine the contents of this application are the student, his/her parents, employees at the school attended, and authorized Upward Bound staff.
Parent/Guardian Signature*

Clear
*In order to sign: position mouse over the designated signature area, hold the mouse button down, then proceed to drag in the form of your signature.
Date Signed

MonthDayYear
mm-dd-yyyy

Submit
Please verify that you are human*
Should be Empty: