Prince George's Community College-VUB-Application Form

Participant Application

Step 1: Please answer the following questions about yourself
What is your legal name?*

First NameMiddle Initial Last Name
What is your mailing address?*

Street Address

Apt. #

CityState

Zip Code
What is your cell phone number? *
(999)999-9999
What is your secondary phone number?
(999)999-9999
What is your email address?*
example@example.com

Step 3: Please answer the following question about yourself
Are you a U.S. Citizen?*

YesNo, but I am a Permanent Resident.No, I am not a U.S. citizen, and I am not a permanent resident.
Are you a permanent resident, if so your alien number?

Step 4: Please answer the following questions about your parents/guardians.
Has either your mother or father (biological or adoptive) received/earned a bachelor’s degree from college?*

YesNo

Step 5: Please answer the following questions about yourself.
Are you currently enrolled in college?

YesNo
If so, where?
Has it been 5 or more years since you last enrolled in college?

YesNo

Please answer the following questions about yourself.

	Yes	No
I served more than 180 days of active duty service and was discharged or released under conditions other than dishonorable.
I did not serve more than 180 days of active duty service but was discharged with a service-connected disability
I was a member of a reserve component of the Armed Forces call to active duty for a period of more than 30 days.
I was a member of a reserve component of the Armed Forces who served on active duty in support of a contingency operation on or after September 11, 2001.

Step 6: You must answer the following questions about yourself if you are at least 24 years old or you answered YES to any question in STEP 5.Your parent/guardian (s) must answer the following questions about themselves if you are less than 24 years old and you answered NO to all questions in STEP 5.
What is the total number of people (including you) in your household?*
What was your family’s taxable (not total) income from the last calendar year?(Please check only one box. Then, provide the requested income information.)

My family’s taxable (not total) income from the last calendar year was: _____________Note: Taxable income can be found on the federal income tax return. On IRS Form 1040, see line 11b (as of 2018).My family did not file a federal income tax return for the last calendar year. My family’s total income from the last calendar year was: _____________My family had no taxable income during the last calendar year. If your family did not have to file taxes, please provide an IRS non-filer document stating they were not required to file taxes.
Here are three ways to request IRS Verification non-filing status:
- Online
- Over the phone by calling 1-800-908-9946
- Mailing in a form (see link below, click to complete form, check question 7; sign, date, add phone number, and mail according to state of residence included on page 2 of instructions).
Form 4506T https://www.irs.gov/pub/irs-pdf/f4506t.pdf
If selected option one
If selected option two

Step 7: Please read the following statement and then sign and date the application. If you (the student) are less than 24 years old and answered NO to all the questions in STEP 5, your parent or legal guardian must also read the following statement and then sign and date. If you are older than 24 years old, please read, sign, and date the statement.
Completion of this application and submission of supplemental documents do not guarantee admission into the program. A determination of your admission into the program usually occurs within 24-48 hours. By signing this application, I attest that all the information on this application is true. Moreover, I authorize the release of the student’s official academic records to the TRiO Veterans Upward Bound (VUB) program at Prince George’s Community College, understanding that the information in these records will be used only to assess the student’s need for VUB program services, discern the student’s educational progress, evaluate the effectiveness of VUB program activities, and fulfill VUB program-reporting requirements. I also acknowledge the nature of such activities or trips may expose me to hazards and risks. In consideration of me being permitted to participate in the event, I hereby accept all risk to my health and of my injury or death that may result from such participation, and I hereby release Prince George’s Community College, its governing board, officers, employees and representatives from any and all liability to me, my personal representatives, estate, heirs, next of kin, and assigns for any and all claims and causes of action for loss or damage to my property and for any and all illness or injury to my person, including my death, that may result from or occur during my participation in the activity or trip, whether caused by negligence of Prince George's Community College, its governing board, officers, employees, or representatives, or otherwise. I further agree to indemnify and hold harmless Prince George's Community College, its governing board, officers, employees, and representatives from liability for the injury or death of any person(s) and damage to property that may result from my negligent or intentional act or omission while participating in a TRiO VUB event. Finally, I authorize this VUB program to use my name or the student’s name, statements and likeness, without charge, for promotional purposes in the project’s publications, advertising, video, and other formats.
Student's Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Signature of Student’s Parent or Legal Guardian (applicable if less than 24 years old)

Clear
Date

MonthDayYear
mm-dd-yyyy

Participant Application