Central Carolina Community College-VUB-Application Form

Veterans Upward Bound Program

Application for Services

Personal Information
Name*

First NameMiddle InitialLast Name
Social Security Number
999-99-9999
Date of Birth

MonthDayYear
mm-dd-yyyy
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address*
example@example.com
County

ChathamHarnettJohnstonLeeWakeOther
Emergency Contact

First NameLast Name
Contact Phone
(999)999-9999
Day Phone
(999)999-9999
Evening Phone
(999)999-9999

Education
High School
Have you completed High School?

H.S. GraduateG.E.D. GraduateNot completed
Date of Last Enrollment

MonthDayYear
mm-dd-yyyy

Did you take the SAT and/or ACT?

	Score
SAT
ACT

College
Have you completed a college degree?

Associate's DegreeBachelor's DegreeNot completed
College/University and Program Major?
Date of Last Enrollment

MonthDayYear
mm-dd-yyyy
Do you have a defaulted student loan?

YesNoUnsure
What is your future education/career goals?

Income - Complete ONE of the two sections below
Complete this item if you DID file a tax return last year.
I filed an income tax return last year. The number of individuals currently living in my household and/or claimed as dependents (including myself) is
My total taxable income for last year was
(Form 1040 line 43 or Form 1040A line 27). Please note that taxable income is different from gross or net income.
*If available, please mail a copy of your 1040 or 1040A to our office as soon as possible.
Complete this item if you were NOT required to file a tax return last year.
I was not required to file a tax return last year. The number of individuals currently living in my household and/or claimed as dependents (including myself) is
My total non-taxable income for last year (from all sources) was
*If you did not file but have other non-taxable income please complete the other income verification document.
Signature

Clear
Date

MonthDayYear
mm-dd-yyyy

Family Income Statement
Check below if you are currently unemployed AND your family's current taxable income is $0.

Check here if you are currently unemployed AND your family's current taxable income is $0.

Please complete the table below to document any untaxed income

	Amount
a. Child Support
b. Worker's Compensation
c. Untaxed Pension
d. Supplemental Security Income (SSI)
e. Veteran Disability Benefits
f. Other

I certify that all the information reported on this form is coplete and accurate to the best of my knowledge.
Signature

Clear
Date

MonthDayYear
mm-dd-yyyy

Enrollment Contract
Participant Name

First NameLast Name
Date

MonthDayYear
mm-dd-yyyy
I, {part_name}, accept the offer to join the Veterans Upward Bound (VUB) Program at Central Carolina Community College (CCCC). I agree to take full advantage of all the programs and services that the VUB program provides. Specifically, I commit to:
- Participate in the VUB Orientation.
- completing the pre and post testing.
- fully participate in VUB remedial refresher course materials and tutorial services, as needed.
- attend VUB workshops, professional development programs, and cultural enrichment activities
- identify potential academic major(s), complete and submit all admission/financial aid forms for enrollment, and attend an institution of higher education.
- complete a post secondary credentials.
- observance the rules established by the VUB Program and the host institution, Central Carolina Community College.
I understand that a violation of this commitment may jeopardize my eligibility for participation in the Veterans Upward Bound Program.
Participants' Signature

Clear
Date

MonthDayYear
mm-dd-yyyy

Consent to Release Form
Participant Name

First NameLast Name
Date

MonthDayYear
mm-dd-yyyy
I, {part_name2}, am part of the Veterans Upward Bound (VUB) Program that serves Chatham, Harnett, Johnston, Lee, and Wake counties. From time to time, VUB will need to have access to my electronic student records, including financial aid and student accounts for the purposes of reporting to the Department of Education. With this signed disclosure I give staff members at VUB consent to gather the necessary data that they need. Specifically, I allow VUB access to:
- my academic placement testing scores.
- grades, program completion information, and attendance information.
- veterans services information such as my DD214 (if on file and VA payment/Chapter info.
Under the Family Educational Rights and Privacy Act (FERPA) of 1974, electronic student records, including financial aid and student accounts, are considered confidential and will not be released without written consent from the student.
Participants' Signature

Clear
Date

MonthDayYear
mm-dd-yyyy

Liability Release Form
Liability Release Form

The Veterans Upward Bound Program Central Carolina Community College
I, do hereby release, forever discharge and agree to hold harmless Central Carolina Community College, the Veterans Upward Bound Program and the staff thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by myself while participating in the Veterans Upward Bound Program. Furthermore, I hereby assume all risks of personal injury, sickness, death, damage and expense as a result of participation in recreation, any travel/transportation, and work activities involved therein. I further hereby agree to hold harmless and indemnify said college or university, its administrators, employees, for any liability sustained by said initiative as the result of the negligent, willful or intentional acts of said participant, including expenses incurred attendant thereto.
Name of Participant

First NameLast Name
Signature of Participant

Clear
Date

MonthDayYear
mm-dd-yyyy

Insurance Information
Health Insurance
Name of Company
Policy Number

Emergency Contacts / Next of Kin
Name

First NameLast Name
Relationship
Phone #
(999)999-9999
NOTE: This information is strictly for the use of VUB and will not be released to anyone without your knowledge and written consent.

Consent for Use of Photograph, Image and/or Participant Work
Consent for Use of Photograph, Image and/or Participant Work

Veterans Upward Bound

Central Carolina Community College

In consideration of the possible use of my image and other information pertaining to my name in the medias set out below, I hereby give my consent for the Central Carolina Community College (CCCC) Veterans Upward Bound (VUB) Program to use my image and information in the ways indicated below.

I give the CCCC VUB Program the irrevocable right and permission to copyright, use, re-use, publish, re-publish, exhibit, and distribute my image (including photographs and videotaped images), interviews and samples of in displays, in Veterans Upward Bound publications, in instrutctional videos and/or on the internet. I give this permission on the condition that I will not be identified by name, nor will I be identified by my name, for any image used on the internet, I waive the right to approve the final product(s) in which these images and samples may appear.
Permission

I give VUB permission to use photography and/or name to be published.I do not give VUB permission to use photography and/or name to be published
Name of Participant

First NameLast Name
Signature of Participant

Clear
Date

MonthDayYear
mm-dd-yyyy

Internet Use Agreement
Internet Use Agreement

Veterans Upward Bound

Central Carolina Community College

I agree that the following actions constitute unacceptable use of the Internet. Whether that use is initiated from the Veterans Upward Bound (VUB) Program or another site, and I shall not perform any of these actions at any time when access to the Internet is in any way related to my status as a participant of the VUB program.

1. Using impolite, abusive, or otherwise objectionable language in either public or private messages;
2. Placing unlawful information on the Internet;
3. Using the Internet illegally in ways that violate federal, state, or local law or statues;
4. Using the Internet during a VUB program or event for non-educational purposes;
5. Sending chain letter, pyramid schemes, or any other type of use that would cause congestion of the Internet or otherwise interfere with the work of others;
6. Using the Internet for commercial purpose;
7. Using the Internet for political lobbying;
8. Changing any computer file that does not belong to the user, without permission from the owner of the computer file;
9. Sending or receiving copyrighted materials without permission;
10. Knowingly giving one’s password to others;
11. Using another person’s password;
12. Using Internet access for sending or retrieving pornographic materials, inappropriate text files, or files dangerous to the integrity of the network;
13. Circumventing security measures on school or remote computers or networks;
14. Attempting to gain access to another’s resources, program, or data, without authorization from the individual or group, or without the person(s) in charge’s written permission.
15. Vandalizing, which is any attempt to harm, destroy data of another user on the Internet, including the uploading or creation of computer viruses; or
16. Falsifying one’s identity to others while using the Internet.

Participant’s Agreement
I have read the Internet Use Agreement, and I understand it fully and agree to refrain from all of the unacceptable actions listed in the Agreement. I understand that internet access which is provided is designed for educational purposes. I understand further that any violation of the Internet Use Agreement is unethical and may constitute a criminal offense. Should I commit any violation of this agreement, my access privilege may be revoked and, if Veterans Upward Bound Program behavioral expectations or laws are broken, disciplinary and/or appropriate legal action may be taken.
Name of Participant

First NameLast Name
Signature of Participant

Clear
Date

MonthDayYear
mm-dd-yyyy

Stipend Verification Form
STIPEND VERIFICATION FORM

Veterans Upward Bound
Participant Name

First NameLast Name
Mailing Address

Street and/or PO Box

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
(999)999-9999
Cell Phone Number
(999)999-9999
Social Security Number
999-99-9999
Student Signature

Clear
Date

MonthDayYear
mm-dd-yyyy

Liability Release Form

STIPEND VERIFICATION FORM