Miami Dade College Homestead-UB-Application Form

First-Generation VerificationStudents and Parents are required to submit this application together. Please ensure that both parties are present when submitting the application

Miami Dade College
TRIO Upward Bound

Dear Applicant,

Thank you for your interest in the TRIO Upward Bound Program at Miami Dade College, Homestead. TRIO Upward Bound is designed for students with academic potential who need additional preparation and motivation to succeed in high school and later, in college. TRIO Upward Bound Program is a year-round program. The program provides on-going academic preparation, counseling, and enrichment activities.

Eligibility to participate in the program is determined individually. However, each applicant must meet basic eligibility requirements set forth by the federal government. Our Upward Bound Program serves a limited number of students. Therefore, it is important that you complete your application as soon as possible. When space is not available, an applicant may be referred to our waitlist for later consideration.

There is a six-week summer program offered first to students who have participated in the year-round portion, and have sufficient summer attendance and satisfactory grades. The summer program is designed to simulate the experience of attending college. The summer program focuses on academics and enrichment activities.

Below you will find instructions for completing the application process. Applications are accepted and reviewed year-round but students are only accepted if space permits. Once your application is received, you will be notified of your application status. We look forward to you being a part of our family!

All of the information contained in this application will remain confidential by the Miami Dade College Upward Bound staff in determining the eligibility of a student. Students selected for an interview will be contacted by our office.

Miami Dade College Homestead Upward Bound Program Office:

Miami Dade College, Homestead Upward Bound
500 College Terrace, Room H-202-04
Homestead, FL 33030
PH: 305-237-5076
UBHomestead@gmail.com

Jasmine Johnson
Director, Upward Bound
PH: 305-237-5076
Email: jjohnso9@mdc.edu

Important Parent Note: UB is a free, academic support program provided through funding from the U.S. Department of Education. Students will have participation objectives, but the program will work to balance other high school commitments such as sports team involvements, other academic interests, and community service.

Parent/Guardian Information
Must be completed by a Parent or Guardian
Parent/Guardian 1 Name*

First NameLast Name
Relationship to Student*
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian 1 Cell Phone*
(999)999-9999
Are you the Primary Contact?*

YesNo
Parent/Guardian 1 Email*
example@example.com
Parent/Guardian 2 Name

First NameLast Name
Relationship to Student
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian 2 Cell Phone
(999)999-9999
Are you the Primary Contact?

YesNo
Parent/Guardian 2 Email
example@example.com
In case of an emergency, parent(s)/guardian(s) or the two alternate persons listed below should be contacted:

ALTERNATE EMERGENCY CONTACT #1
Alternate's Name

First NameLast Name
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current Home Phone
(999)999-9999
Cell Phone
(999)999-9999
Relationship to Student
ALTERNATE EMERGENCY CONTACT #2
Alternate's Name

First NameLast Name
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current Home Phone
(999)999-9999
Cell Phone
(999)999-9999
Relationship to Student

Consent Form for Mutual Exchange of Information
Must be completed by a Parent or Guardian
Date

MonthDayYear
mm-dd-yyyy
Student's Name

First NameLast Name
Date of Birth

MonthDayYear
mm-dd-yyyy
Miami Dade Public Schools Student ID#
I hereby authorize the mutual exchange of records pertaining to my child or myself, {main_name}, between the MIAMI-DADE COUNTY PUBLIC SCHOOLS and the following agencies (include all schools, physicians, psychologists, hospitals, clinics, etc., that have had significant contact with your child):

Miami Dade College - TRIO Upward Bound

500 College Terrace, Room H-202-04 Homestead FL 33030
- The specific records to be disclosed pertain to: Report Cards, transcripts, FSA Scores, IEP's, College readiness assessments, Attendance Records, and any other Relevant Academic Information
- The purpose for making these records available is: To assist this student in their academic and personal improvement through the Upward Bound program.
- The receiving party will not disclose the information to any other party without signed consent.
I certify that I am the parent or legal guardian of the child named above or that I am a student of majority age and have the authority to sign this release.
Parent/Guardian Name

First NameLast Name
Signature

Clear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code