Neosho County Community College-UB-Application Form

Neosho County Community College Upward Bound Student Application.

Neosho County Community College (NCCC) Upward Bound (UB) is a college preparatory program funded by the US Department of Education. Upward Bound aims to enhance academic achievement in high school and generate the skills and motivation for participants to enter and succeed in post-secondary education, college, or technical schools. We seek high school students from low-income families, students on track to be the first person in their family to attend college (first-generation), and students at high risk for academic failure. We are funded to serve 55 high school students in Chanute, Humboldt, Erie, and Iola – out of those 55, 2/3 of them must be BOTH first-generation and low-income. To meet their needs, we provide three main types of services – Weekly Meetings (once a week), Saturday Academies (once a month), and the Summer Program (once a year).

Confidentiality Statement:

The personal information you give to the NCCC Upward Bound Program is required by the United States Department of Education. The Privacy Act protects this information. No one may see the information unless the Upward Bound Program employs them or they are expressly authorized to determine your participation eligibility. The information required by the United States Department of Education is used for evaluation, program purposes, and to verify student eligibility. The utmost care is taken to ensure that the personal information collected concerning Upward Bound students and guardians remains confidential. Information or records relating to current or former Upward Bound students or groups of students will not be disclosed to any person, group, agency, or organization without further written permission from each student or parent/guardian.

The Upward Bound Program at Neosho County Community College is 100 percent federally funded by the United States Department of Education, with an annual budget of $309,505 to serve 55 students. Award #P047A221025.

Section 2: Student Contact Info
Address (please notate street as St. or apartment as Apt.)*

Street Address

Street Address Line 2

CityState

Zip Code
Student Cell Phone
(999)999-9999
Student School Email Address*
example@example.com
Student Personal Gmail Address
example@example.com
Student Powerschool Username
Student Powerschool Password

Section 4: Family Income Info
How many people are in your household? (including applicant)*

Please list below the names of ALL persons living in your household, their ages, and their relationship to the student.

	Name	Age	Relation to Student
1
2
3
4
5
6

NCCC Upward Bound is a federally funded program, and government regulations require verification of family income as part of the application/admission process. This information could also help assist your student with information about financial aid, scholarship opportunities, and special programs. Please check your annual TAXABLE INCOME (Line 15 on the 1040 tax form.) PLEASE DO NOT LIST YOUR GROSS (TOTAL) INCOME.
Indicate taxable income*

$0 - $22,590$22,591 - $30,660$30,661 - $38,730$38,731- $46,800$46,801- $54,870$54,871- $62,940$62,941 - $71,010$71,011- $79,079$79,080 or more
I certify that the above information is accurate and complete to the best of my knowledge. I understand that all information provided shall be held in the strictest confidence.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy

Section 6: Student and Parent/Guardian Acknowledgement
The information I (the student) have just provided will assist Upward Bound in determining my eligibility for the Neosho County Community College Upward Bound Program. By signing this document, I verify that all the information given is accurate and complete to the best of my knowledge. I agree to complete any other required paperwork and meet with Upward Bound Staff for a student interview, where I will receive additional information. Pending a successful interview, the student will begin a 60-day probationary period in which they are expected to participate in all program activities before they are officially accepted.
Student Signature*

Clear
Current Date*

MonthDayYear
mm-dd-yyyy
As the parent/legal guardian of the above-listed student, I agree to help my student adhere to these guidelines. By signing this document, I verify that all the information given is accurate and complete to the best of my knowledge. I agree to complete any other required paperwork and understand the next steps my student will take to complete their application and be fully accepted into Upward Bound.
Parent/Guardian Signature*

Clear
Current Date*

MonthDayYear
mm-dd-yyyy
Thank you for your application! After reviewing your application, we will contact the student to set up an interview. If you have any questions, please email ncccub@gmail.com or call 620-432-0367.