Coastal Bend College-Rural-UB-2021 Application

STUDENT APPLICATION
Upward Bound Rural does not discriminate on the basis of race, creed, color, national origin, sex, age or disability. The personal information you give on the application is protected by the Federal Privacy Act. The U.S. Department of Education has the authority to gather information on all Upward Bound Rural participants to determine eligibility and monitor their progress. No one may see any information unless they are specifically authorized. Upward Bound is a 100% federally funded program.

UB Parent Information (To be completed by Parent/Guardian)
Students Name:*

FirstMiddleLast
Who do you live with?*
Parent/Guardian Name:*

First NameLast Name
Home Phone
(999)999-9999
Cell Phone*
(999)999-9999
Email address:*
example@example.com
Mailing Address*

PO Box/Street

Street Address Line 2

CityState

Zip
Father/Guardian Name:

First NameLast Name
Home Phone
(999)999-9999
Cell Phone
(999)999-9999
Email address:
example@example.com
Mailing Address

PO Box/Street

Street Address Line 2

CityState

Zip
Has your Mother receive a 4 year degree from a university:*

YesNoDon't Know
Has your Father receive a 4 year degree from a university:*

YesNoDon't Know

Financial Information
What is the total number of persons (including you) in your household?*
What was your family's taxable (not total) income from last calendar year? (Please check only one box. Then, provide the requested income information.*

My family did file a federal income tax return for the last calendar year. My family's taxable income is listed below.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 is listed belowMy family had no taxable income during the last calendar year.
What was your family's taxable (not total) income from the last calendar year?*

Federal regulations require that verification of family income must be submitted as part of the application/admission process. If you did not file income tax last year what type of income did you receive?*

	Income Amount
How much income did you receive in Social Security last year?
How much income did you receive in Child Support last year?
How much income did you receive in Welfare (TANF/AFDC) last year?
How much income did you receive in unemployment last year?

I the undersigned, certify there is no intent to commit fraud. I certify that to the best of my knowledge, the above information is complete, and true. I am also aware that the information provided will be used to determine eligibility and that it is subject to external verification and may bereleased for such purposes.
Students Signature *

Clear
Date*

MonthDayYear
mm-dd-yyyy
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy

Documentation Checklist
Documentation Checklist

Students will not be considered for the Upward Bound Rural program if the following documentation is not provided.

Documentation checklist:
- Complete Upward Bound Rural Application
- Autobiography
- Ferpa form
** Only students with complete application packets will be interviewed. **

TRIO Upward Bound Rural Academic Director

Adriana Jimenez

Ajimenez10@coastalbend.edu

361-354-2708

TRIO Upward Bound Rural Success Coach

Stephanie Hollis

shollis@coastalbend.edu

361-354-2746
Autobiography Writing Sample
(3-5 sentences) - Childhood (Birth/Home life/Early Education) Tell us about your childhood. Where did you live, how was your school and family life?*
(3-5 sentences) - Tell us about your youth (Education/ Jobs/ Interests/ Hobbies/ School, and other Activities)*
(3-5 sentences) - Tell us about your future. (Life Goals, Career Plans, Etc.)*
(3-5 sentences) - Have you ever done any Volunteer Work or Community Service or any kind with School, Church or parents? Explain.*
Upload a copy of your Tax Files or proof of income*

Cancelof
Upload a copy of your transcript*

Cancelof
Upload a copy of your report card*

Cancelof
Upload a copy of your current class schedule*

Cancelof

FERPA Form
Name*

First NameLast Name
I, _{name}_ herby authorize release of my educational and employment records to the Coastal Bend College Upward Bound program. The type of information that is to be released under this consent form includes:
- Transcripts
- School Enrollment Status
- School Credits Completed
- Degrees Earned
- Employment Status
- Employment History
- Disciplinary Records
- Recommendations for employment or admissions to schools
- Other Information Related to Education and Work Performance
The above information is to be released for purposes of verifying placement and retention in college and/or employment and for Career and Education Services staff to provide support with retention in college and employment. This information will only be shared with program staff and program funders. I understand the information may be released orally or in the form of copies of written records, as preferred by the requester. I understand that I have a right to inspect any written records released pursuant to this Consent. I understand I may revoke this Consent upon providing written notice to CBC Upward Bound. I further understand that until this revocation is made, this consent shall remain in effect and my educational and employment records will continue to be provided to the Upward Bound program for the specific purpose described above.
Participant Name*

First NameLast Name
Participant Signature*

Clear
Participant Social Security Number*
999-99-9999
Parent Name*

First NameLast Name
Parent Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy

STUDENT APPLICATION