Northwest Shoals Community College-Muscle-UB-ApplicationForm

STUDENT APPLICATION

Northwest Shoals Community College
Upward Bound – Shoals Campus

Northwest-Shoals Community College

800 George Wallace Blvd. - Muscle Shoals, AL 35661

Office: (256) 331-5355
- Applicant must be in the 9th - 12th grade.
- Applicant must be a student at Central, Colbert County, Colbert Heights, Florence, Lexington, Rogers, Sheffield, or Wilson High School.
- If you need assistance completing the Application, please call our office at (256) 331-5355.
To complete application:

1. Application Completed & Signed

2. Parent/Guardian Income Tax Forms from Last Year (Last Taxes You Filed)

3. Teacher’s Recommendation Form

4. Test Scores – (8th SDE Scantron Reading & Math * 9th & 10th Pre ACT 11th & 12th ACT & 12th Grade Work Keys)

5. Transcript

HOUSEHOLD INFORMATION
HOUSEHOLD INFORMATION
With whom does the student live with?

Both ParentsMother onlyFather onlyGrandparentFoster CareOther
Father or Guardian's Name

First NameLast Name
LivingDeceased
Home Phone
(999)999-9999
Cell Phone
(999)999-9999
Employer
Work Phone
(999)999-9999
Email Address
example@example.com
Mother or Guardian's Name

First NameLast Name
LivingDeceased
Home Phone
(999)999-9999
Cell Phone
(999)999-9999
Employer
Work Phone
(999)999-9999
Email Address
example@example.com

Please list everyone who lives in the house with the applicant. (including the applicant who is applying to enter the program and the relationship to the applicant):

	NAME	RELATIONSHIP TO STUDENT
1.
2.
3.
4.
5.
6.
7.
8.
9.

Upward Bound is an on-going program. If you accept an invitation to participate in the program, you are required to attend tutoring and workshops throughout the school year, during the summer component and until you graduate from High School.
Are you willing to continue in Upward Bound until you graduate from high school?

YesNoNot Sure
Are you willing to attend weekly tutoring sessions after school?

YesNoNot Sure
Are you willing to attend scheduled Saturday activities?

YesNoNot Sure
Are you willing to attend a six weeks Summer Component?

YesNoNot Sure
T-Shirt Size

EXTRA-CURRICULAR ACTIVITIES
Extra-curricular activities at school:

STUDENT ESSAY
STUDENT ESSAY
Please provide an essay explaining your interest in the Program, educational goals, career goals, family history and how you would benefit from this Program.

READ CAREFULLY
PLEASE READ CAREFULLY BEFORE SIGNING

*We certify that to the best of our knowledge the information above is correct and complete.

*We give our permission to Upward Bound to obtain any and all of the applicant’s academic records including, but not limited to: transcripts, test scores, grade reports, attendance records, agency records, and other relevant documents. This permission granted is effective throughout high school, college career, and includes final transcripts upon graduation from secondary school and college.

*If the applicant is selected for Upward Bound, he/she has my permission to participate in all Upward Bound activities, make all scheduled trips, and to attend the six-week summer program (if applicable).

*We also give our permission for the participant’s name and photo to be used in any media presentation concerning the Upward Bound Program.

*We agree to provide proof and documentation of all information stated on this application.
Applicant's Signature

Clear
Date

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

Clear
Date

MonthDayYear
mm-dd-yyyy

INCOME VERIFICATION
INCOME VERIFICATION

This section must be completed by the parent/guardian of the applicant. Eligibility is based upon “Taxable” rather than “gross” income and based upon federal guidelines from the U.S. Department of Education.

Please sign your taxes on the first page.

If you filed a 1040 or 1040A from Last Year. (A Copy of your TAXES must be attached to this Application!)

Please include a signed copy of last years tax return with this application.
1040 Form – Enter Taxable Income amount from Line 10
1040EZ – Enter amount Taxable Income
1040A Form – Enter amount Taxable Income
Total number in household (including self and dependents)
Please include a signed copy of last years tax return with this application.

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If you did not file taxes last year, please complete the following questions.
List your estimated income
Total number in household (including self and dependents)
Social Security
Disability
Unemployment
(If you receive social security, disability, etc., please include a copy of your award letter with this application)

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THE STUDENT’S APPLICATION

CANNOT BE PROCESSED

WITHOUT THE REQUIRED INCOME INFORMATION.

Under penalties of perjury, I declare that to the best of my knowledge and belief, the information is true, correct, and complete.
Parent/Guardian's Signature

Clear
Date

MonthDayYear
mm-dd-yyyy

STUDENT APPLICATION