Long Beach Community College District-UB-Application Form

Long Beach City College Upward Bound Program

PLEASE MAKE SURE YOU HAVE COMPLETED OUR ELIGIBILITY FORM BEFORE PROCEEDING WITH THE APPLICATION. CONTACT wporter-coste@lbcc.edu OR a2sanchez@lbcc.edu TO INQUIRE ABOUT THE FORM

The Long Beach City College Upward Bound Program is a federally funded initiative that encourages eligible students to complete high school successfully and continue on to postsecondary education. Participants must meet the eligibility criteria of being low-income and/or first generation. Completing this eligibility form does NOT mean you have been accepted into the program. However, we review all eligibility forms and schedule an information session and interview with students who are eligible. Please complete the following documents below and a member of our team will be in contact with you soon.

If you have any questions, please contact upwardbound@lbcc.edu or by phone at (562) 938-3293. All information provided will be kept confidential.
Student Name*

First NameLast Name
Student School ID Number
High School Attending
Grade
Birthdate

MonthDayYear
mm-dd-yyyy
Birthplace
Ethnicity
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Cell
(999)999-9999
Parent/Guardian Cell
(999)999-9999
Student Email*
example@example.com
Parent Email
example@example.com
High School Counselor Name

First NameLast Name
1. Are you currently enrolled in Talent Search, EOP, or Gear Up?

YesNo
2. Do you wish to attend college after you graduate from high school?

YesNo
3. Did you pass the ELA caaspp, standardized testing?

YesNo
Math CAASPP, standardized testing?

YesNo
4. What is your current overall GPA?
Please attach current progress report or unofficial transcript

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5. Are you a U. S. citizen or resident?

YesNo
How did you hear about Upward Bound?
Did either of your parent's earn a bachelor's degree?

YesNo
7. Do you have a family member in the program?

YesNo
If yes, who?
Family Information
8. Parent/Guardian Name

First NameLast Name
Occupation
9. Parent/Guardian Name

First NameLast Name
Occupation
Education background (Please mark the appropriate box and identify the birth parent who has the highest level of education)
10. Highest education level or degree your birth parent(s) completed

UnknownMiddle SchoolHigh SchoolA.A/A.S.B.A./B.S.Other
Birth parent with highest education level

MotherFather
11. Does your parent/guardian receive CalFresh, CalWORKs, Kin-GAP or SSI?

YesNo
12. How many people are there in your "household"?
('household' is defined as the total number of persons who are related to you by blood, marriage or adoption and are dependent on the head of the household for support. A stepparent or stepchild is considered related by marriage.)
13. Is your parent/guardian required to file an income tax form?

YesNo
14. What was your parent/guardian's taxable income? (This information can be found on any of the forms listed below)
IRS FORM 1040----LINE 37; IRS FORM 1040A--LINE 22; IRS FORM 1040EZ--LINE 6
I certify that the information I have given on this application is true. I agree for the release of my/my child’s high school and postsecondary academic records to the LBCC Upward Bound Program.
Student Name

First NameLast Name
Student Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Parent/Guardian Name

First NameLast Name
Parent/Guardian Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
The LBCC Upward Bound Program complies with Federal civil rights law and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Funded by the U.S. Department of Education.

If you have questions, please call Wendy Porter-Coste, Upward Bound Program Director at (562)938-3176 or Liza Morales, Upward Bound Program Specialist at (323)400-7643 cell. Thank you for your interest and we will contact you for an interview.

ALL INFORMATION PROVIDED WILL BE KEPT CONFIDENTIAL
upwardbound@lbcc.edu (562)938-3176

Emergency Medical Information
Student Name*

First NameLast Name
Student Cell
(999)999-9999
Parent/Guardian Name*

First NameLast Name
Cell
(999)999-9999
Work
(999)999-9999
Parent/Guardian Name*

First NameLast Name
Cell
(999)999-9999
Work
(999)999-9999
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
(999)999-9999
Emergency Contact Information

For emergencies only (24 hours) if unable to contact parent/guardian, please contact:
Emergency Contact Name*

First NameLast Name
Relationship*
Cell Phone
(999)999-9999
Other Phone
(999)999-9999
Physician Information: (if applicable)
Primary Care Physician
Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician Phone
(999)999-9999
General Medical History
(Please check yes or no for each item and please answer all questions)

Do you currently have or have a history of*

	Yes	No
Respiratory problems? Asthma?
Gastrointestinal disturbances?
Migraine headaches?
Skin disorders?
Diabetes?
Cardiac problems? Heart murmurs? High Blood Pressure?
Neurological conditions? Seizures?
Muscular−skeletal conditions?
Any chronic medical conditions?
Dietary restrictions or preferences?
Anxiety?
Depression?

Please comment on all 'yes' answers

Student Allergies*

	Yes	No
Any type of food?
To bee or other insect stings?
Any other allergies (medications, pollen, animals, etc.)?

Please comment on all 'yes' answers

Does parent give permission for student to take any of the following if requested by student?*

	Yes	No
Ibuprofen (Advil/Motrin)
Acetaminophen (Tylenol)
Antacids

Is student currently taking any medications?*

YesNo
Please specify below. Include any medications you carry for possible use, e.g. inhaler, bee sting kit, medication, condition, dosage (amount/frequency) current or potential side effects, restrictions
Does the student have health insurance?*

YesNo
Health Insurance Carrier
Policy Number
Group Number
Name of Policy Holder

First NameLast Name
Relationship to Student
Policy Holder's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Learning Challenges
Does the student have a diagnosed learning challenge?
Does the student have an IEP or soy?
Medical: I give my permission for treatment in case of illness or accident while participating in the LBCC Upward Bound Program. I understand that a doctor or hospital would administer whatever emergency treatment deemed necessary until I can be reached.

Release of Liability: I agree that the LBCC Upward Bound Staff and Long Beach City College Districts and/or the USDA shall not become liable or responsible in any way whatsoever for any injury, accident, illness, or death occurring during or by reason of his/her participation in the LBCC Upward Bound Program. All of the above information is true and accurate. If any information is misstated or falsified, I understand that this application may be denied.
Print Name (parent/guardian)*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy

Confidentiality of Information
Confidentiality of Information

This information is protected by the Family Educational Rights and Privacy Act of 1974. No one may see the information unless they work with or for the Long Beach City College Upward Bound Program or are specifically authorized to see the information. The information is necessary to help determine the success of participants in obtaining post-secondary education. The personal information that you provide the Long Beach City College Upward Bound Program may be shared with the U.S. Department of Education. The Department of Education has authority to gather information to help make Upward Bound a better program for future participants.
Student Name

First NameLast Name
Student Signature

Clear
Date

MonthDayYear
Date
Parent Name

First NameLast Name
Parent Signature

Clear
Date

MonthDayYear
Date

Information Authorization Release
Name of School Attending*
I authorize {school} to release official transcripts, test scores, and other records to the Long Beach City College Upward Bound Program for evaluation purposes. I also authorize the LBCC Upward Bound Program to further release these records to other schools/institutions as they relate to my child’s educational planning.
Social Security #
XXX-XX-9999
Student Name*

First NameLast Name
Student School ID Number*
IMPORTANT: Please attach a copy of your high school transcript and a copy of your most recent state standardized test scores to the LBCC Upward Bound application. If you do not have these forms available, please skip.
High School Transcript

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Standardized Test Scores

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Student's Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Signature of Parent/Guardian*

Clear
Date*

MonthDayYear
mm-dd-yyyy

Income Verification
Student Name*

First NameLast Name
Social Security (last four digits)
XXX-XX-9999
Income Verification for {studentName73}

In order to establish student eligibility for the Upward Bound Program, we need to know the household’s annual taxable income.
Total number of people in household*
Wages and salary*
Before Taxes
Retirement benefits*
$------
Social Security Income (SSI)*
$------
Public Assistance*
$------
Other*
$------
Taxable income from your income tax form (see line 43 on form 1040, line 27 on 1040 A, line 6 on 1040 EZ) for the past year*
$------
This is self-reported by
Parent/Guardian Name*

First NameLast Name
Parent Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy

Liability Release
Student Name

First NameLast Name
Dear Parent(s)/Guardian(s),

During the time of which your son or daughter is enrolled in the Long Beach City College Upward Bound Program, he/she will be expected to participate in many activities, such as cultural and educational events, meetings, classes, tutorial sessions, summer activities, etc. We will be very careful about the safety of your child at all times. The Program, however, requests your signature in agreement with the following statement:

I, {studentName87}, in full recognition of the possible dangers and hazards inherent in any student activity of the sort the Program conducts, do hereby agree to assume all of the risks and responsibilities surrounding my participation in the Program activities, and further, hereby defend, hold harmless, indemnify, release and forever discharge Long Beach City College, the Program and all of their officers, agents and employees from any and all claims, demands and actions, or cause of actions on account of damage to personal property, personal injury or death which may result from my participation, and which result from causes beyond the control of and without any fault or negligence of Long Beach City College, the Program, their officers, agents or employees, during the period of enrollment and/or participation as previously mentioned.
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy

Parent Contract
By enrolling your child/ren in the LBCC Upward Bound Program (LBCC UBP), please be aware that we are requiring parents commit to the following:
- Understand your child/ren will receive a quality education as determined by the collaborative efforts of the LBCC UBP and Long Beach Community College District;
- Strive to actively engage with the LBCC UBP, and become informed about the expectations required and commit to supporting the program 100%;
- Support and uphold the rules and regulations set forth by the LBCC UBP, such that the social and emotional well-being of each child reflects the good character of the students enrolled in the program;
- Support your child’s education in the home by recognizing the adverse developmental impact in exposing children to a range of electronic technologies, (TV, game consoles, computer etc) and how it can potentially have a negative impact on their commitment to academics;
- Attend monthly parent meeting and all meetings conducted by the program;
- Participate in our annual Holiday Event, Academic End-of-Year and, Summer Awards Ceremony;
- Attend school related activities and meetings that support and encourage your child’s academic and personal growth;
- Responsible for ensuring your child’s full participation in academic year (a minimum of four hours every other week) and summer program (full participation during the designated six weeks);
- Assist in your child/ren reaching the overall goal of the LBCC UBP – to be college-ready upon high school graduation and successfully completing a college degree;
- Must submit all needed documentation to Upward Bound staff, if an identified specific learning or other physical/social/psychological need is present at the time of enrolment or at any later stage in the child’s high school journey;
Please be aware the LBCC UBP is a PRIVILEGE and the expectations of the program are HIGH for ALL students. By signing below, you are making a pledge to uphold the above; failure to adhere to this contract will lead to the suspension and possible dismissal of your child from the LBCC UBP.
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy

Release of Information/Grades
Student Name

First NameLast Name
I, {studentName99}, authorize the release of my high school academic and/or academic related records including test data (scores) and grades to the Long Beach City College Upward Bound Program with the understanding that this information will be used solely for the purpose of assessment and educational planning and counseling.
Student Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Parent/Guardian Signature

Clear
Date

MonthDayYear
mm-dd-yyyy

Student Commitment
Student Name*

First NameLast Name
I, {studentName106} wish to participate on the Long Beach City College Upward Bound Program because I realize its many resources will help me to be successful in college. In order to enroll and remain in good standing with the Program, I agree to:
1. Obey all rules and regulations of the Program
2. Meet all requirements of the Program, such as attending all mandatory meetings and classes, submitting necessary forms in a timely manner, being punctual, completing all paperwork, etc.
3. Attend and participate enthusiastically and wholeheartedly in all Program activities, meetings, summer session classes and activities, tutoring sessions, cultural and educational activities, etc. – throughout my enrollment in the Program.
4. Do my best in school and in the Program’s summer session classes.
5. Not receive any D’s, F’s or U’s on my report cards and progress reports.
6. Not miss more than six days of school during each semester while I am enrolled in the Program. Also, I understand that ten absences from any class may be grounds for dismissal from the Program.
7. Conduct myself in a respectful, ambitious and positive manner throughout the
  duration of my participation in the Program.
8. Be friendly, helpful and sharing with others in the Program.
9. Take responsibility for my actions and realize that each decision I make bears an equal consequence.
10. Complete the Program by enrolling in a college after my graduation from high school and obtaining a college degree.
I understand these statements and realize that any failure on my part to meet any of these commitments may result in my dismissal from the Long Beach City College Upward Bound Program.
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
The Long Beach City College Upward Bound Program is a federally funded initiative that encourages eligible students to complete high school successfully and continue on to postsecondary education. Participants must meet the eligibility criteria of being low-income and/or first generation. Completing this eligibility form does NOT mean you have been accepted into the program. However, we review all eligibility forms and schedule an information session and interview with students who are eligible. Please return completed form to the UB Program Specialist, Ms. Morales, or email a copy to upwardbound@lbcc.edu.

Trip Consent Authorization
Parent/Guardian Name*

First NameLast Name
Student Name*

First NameLast Name
I, {parentguardianName163}, hereby give my permission for {studentName164} to participate in all activities, field trips and tours planned by LBCC Upward Bound Program while he/she is enrolled in the Program.
Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Parent/Guardian Signature*

Clear
Date*

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

Clear
Date*

MonthDayYear
mm-dd-yyyy

Release of Photos
LBCC TRIO Upward Bound
Consent and Release From Liability for
Intended Distribution and Use of Pictures and/or Images Published for Program Use
Participant's Name

First NameLast Name
Date

MonthDayYear
mm-dd-yyyy
I hereby grant permission for Long Beach City College Upward Bound and those acting under its permission to copyright, use, publish, display, produce, duplicate, and distribute the photographic, video, and sound recordings of me, and/or my child during my child’s participation in the LBCC Upward Bound Program; for an announcement, information film clips, or other uses necessary to provide information or advertisement for the production, including Instagram, Facebook, Youtube and Upward Bound website.

I hereby release, discharge, and agree to hold harmless Long Beach City College District and those acting under its permission from any liability to the extent permitted by law, for the preparation, distribution, and use of the product, as described above.

Release and consent for a participant under age 18
Requires signature of a parent or legal guardian below
Parent Name

First NameLast Name
I _{parentName190}_ the parent or guardian of _{participantsName}_ consent and grant permission to all of the foregoing.
Signature Parent and/or Legal Guardian

Clear
Date

MonthDayYear
mm-dd-yyyy
Release and Consent for Adult Participant over age 18

I am over 18 years of age.
Print Name

First NameLast Name
Signature

Clear
Date

MonthDayYear
mm-dd-yyyy

Admissions Essay
Part of the application is also an admission essay in which you should discuss 1) your interests, 2) your educational and professional goals, and 3) your desire to participate in the LBCC Upward Bound Program.
Essay
Essay Upload Option

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Learning Challenges