University Of Maine-Farmington-Foothills-UB-Eligibility Form

This form should be completed by the parent(s) or guardian(s) of the student who is applying to Upward Bound. All information is confidential and is used to determine eligibility for Upward Bound. If you have any questions, please call your Upward Bound representative at 1-888-237-1667.

Student*

First NameMid. Init.Last Name

SS #

999-99-9999

Gender

Student's Address

Street or P.O. Box

Street Address Line 2

CityState

Zip Code

Home Phone #

Cell #

DOB

mm-dd-yyyy

Age

Student's E-mail Address*

example@example.com

Parent or guardian email

example@example.com

High School

Current Grade

County

Is this student in the custody of the Department of Human Services?

(If YES do not fill out the rest of this form. Go to the end, sign, and return to the U.B. office.)

List Every Person Living in the Same House as the Student

Rows	List Every Name	List Every Person’s Relationship to the Student	Last Grade Completed: Grade School (GS 1-12) or College (C 1-4)	Place of Employment	Number of Hours Worked Per Week	Wage Per Hour	Total Weekly Income
1.
2.
3.
4.
5.
6.
7.
8.

If one parent (mother or father) is not living in the student’s home, enter that parent’s name and address below.

Mother's Name

First NameLast Name

Address

Street/P.O. Box)

Street Address Line 2

CityState

Zip Code

Father's Name

First NameLast Name

Address

Street/P.O. Box)

Street Address Line 2

CityState

Zip Code

Will Parent/Guardian file a federal income tax return for 2025?

2025 Taxable Income

*You will find your Taxable Income listed on the following IRS tax form: Form 1040 – Line 15

If 2025 Taxable Income is not available upon completion, please provide 2024 Taxable Income

*You will find your Taxable Income listed on the following IRS tax form: Form 1040 – Line 15

Check (√) all other types of income received by or for any member of the household. Be sure you entered income from work of every person living in your home which you have listed.

Are you eligible for free and reduced lunch?

Are you a citizen of the United States?

If NO, please indicate status and provide documentation

Other

Have there been recent changes in your financial situation?

If YES, please explain.

Do you expect any changes?

If YES, please explain.

What is the student’s racial/ethnic background: (optional)

Do you identify as Hispanic/Latino:

What is the student's racial background?

Do either of the student’s biological or adoptive parents have a bachelor’s degree or a 4 year college degree?

Name of College/University

Does this student have a diagnosed disability?

If YES, please describe disability:

I CERTIFY THAT THE INFORMATION REPORTED ON THIS STATEMENT IS, TO THE BEST OF MY KNOWLEDGE AND BELIEF, TRUE, CORRECT, AND COMPLETE.

(Parent/Guardian Signature)

Relationship to the Student

Date Signed

mm-dd-yyyy

UMF Upward Bound

252 Main St.

Farmington, ME 04938

Web Address: https://www.umf.maine.edu/upwardbound/
Telephone: (207)778-7296
Toll Free: 1-888-237-1667

Non-Discrimination Notice

The University of Maine System (the System) is an equal opportunity institution committed to fostering a nondiscriminatory environment and complying with all applicable nondiscrimination laws. Consistent with State and Federal law, the System does not discriminate on the basis of race, color, religion, sex, sexual orientation, transgender status, gender, gender identity or expression, ethnicity, national origin, citizenship status, familial status, ancestry, age, disability (physical or mental), genetic information, pregnancy, or veteran or military status in any aspect of its education, programs and activities, and employment. The System provides reasonable accommodations to qualified individuals with disabilities upon request. If you believe you have experienced discrimination or harassment, you are encouraged to contact the System Office of Equal Opportunity and Title IX Services at 5713 Chadbourne Hall, Room 412, Orono, ME 04469-5713, by calling 207.581.1226, or via TTY at 711 (Maine Relay System). For more information about Title IX or to file a complaint, please contact the UMS Title IX Coordinator at www.maine.edu/title-ix/.

ELIGIBILITY ASSESSMENT FORM