Mercer County Community College-UB-Application Form

SECTION B: CONFIDENTIAL FAMILY INFORMATION

PARENT/GUARDIAN INFORMATION:
Father/Male Guardian Name*

First NameLast Name
Living with family?*

YesNo
Highest Education Level Completed*

K-89-12High School DiplomaAssociates DegreeBachelor’s DegreeMaster’s DegreeDoctorate Degree
Mother/Female Guardian Name*

First NameLast Name
Living with family?*

YesNo
Highest Education Level Completed*

K-89-12High School DiplomaAssociates DegreeBachelor’s DegreeMaster’s DegreeDoctorate Degree
Are your parents:*

MarriedWidowedSeparatedDivorcedSingle/Never MarriedOther

FAMILY SIZE INFORMATION (Please LIST BELOW ALL LIVING IN HOUSEHOLD)

TOTAL NUMBER IN FAMILY*
(Parents/Guardians and children living in household)
Is the applicant a foster child?*

YesNo
A foster child is considered a “family of one” and the child’s support payment is considered that family’s income.
FAMILY INCOME INFORMATION:
(Include only persons living in household) PROOF OF PARENT/GUARDIAN INCOME INFORMATION FROM THE FEDERAL GOVERNMENT. YOU MUST SUBMIT A COPY OF EITHER:

A BENEFITS VERIFICATION LETTER FROM A SOCIAL SERVICE AGENCY

• Welfare Benefit Statement explaining amount of allotment.
• Social Security Benefit Statement explaining amount of allotment.
• Veteran Administrative Benefit Statement explaining monthly benefits.
• Unemployment Benefit/Award Statement explaining benefits.
• Notarized Letter explaining your situation.
1. FEDERAL INCOME TAX RETURN AND a W2 FORM (Both Signed)

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A BENEFITS VERIFICATION LETTER FROM A SOCIAL SERVICE AGENCY

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Add the amount earned in the 1040 form listed under Taxable Income*

CERTIFICATION

Certifying Signatures
I _________________________________ hereby certify that all answers and information given constitute a full and complete disclosure with respect to this application. I understand that this application is being made in connection with the receipt of federal funds and that the U.S. Federal Government and the U.S. Department of Education may verify this information. Any misrepresentation of facts provided on this application will result in nullification of my application prior to admission or dismissal from the program following admission. I approve of my child/ward applying for this program. In the event my child/ward is accepted into Upward Bound, I authorize his/her participation in classes, research, and other activities as scheduled by the Director of Upward Bound.*

First NameLast Name
Student's Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Parent/Guardian's Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy

ESSAY QUESTION
In 200-500 words, tell us why you would like to be a member of Upward Bound. Write about your strengths, weaknesses, interests, hobbies, and talents. Please include your plans after high school and what or who may have influenced you the most in your life.

0/500
Upload your essay if not typed in the box above

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HIGH SCHOOL RECORD & TRANSCRIPT REQUEST FORM
I, ________________________________(parents' name)*

First NameLast Name
parent/guardian of _______________________ (student name) hereby grant permission for you to release and attach a copy of the high school transcript, current report card, and any other academic related records for the above named student to Upward Bound.*

First NameLast Name
Required by Section 504 Rehabilitation Act of 1973: (Please check the appropriate box where it applies.)

Visual ImpairmentAuditory ImpairmentMotor ImpairmentLearning Impairment
COMMENT(S)

Please list all standardized test taken and attach a copy of results.

SCHOOL INFORMATION:
PRESENT GRADE*

891011
EXPECTED GRADUATION DATE

MonthDayYear
mm-dd-yyyy
Guidance Counselor's Name*

First NameLast Name
Guidance Counselor Email*
example@example.com
Teacher or Community Leader Name*

First NameLast Name
Teacher or Community Leader Email*
example@example.com
High School*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone#*
(999)999-9999
Fax
(999)999-9999
Student's Signature*

Clear
Date

MonthDayYear
mm-dd-yyyy
Parent/Guardian's Signature*

Clear
Date

MonthDayYear
mm-dd-yyyy
Please forward this form along with official transcript, report cards and any additional records to:

Mercer County Community College, Upward Bound
102 North Broad Street
Trenton, New Jersey 08608

UPWARD BOUND APPLICATION