The Renaissance Education Group Inc.-Durham-UB-Parent Application

Be sure to answer all questions and print or type clearly.

If unable to submit application online, please email or fax to:
The Renaissance Upward Bound Program
pcu@renaissance-ed.net
Fax: (866) 770-4766

This form will be used to determine eligibility for program services. Please complete this application in full. All of the information collected will be held in the strictest of confidence. Applications will be processed once all materials are received. Admission into the program will be based on eligibility, need, and readiness for the program. For additional questions, please call (919) 416-1736.

Child’s Name

First NameMILast Name

Child's Current School:

Other

Child's Grade Level:

Child’s Social Security Number (last 4 digits):

999-99 - __ __ __ __

Child’s Date of Birth (mm/dd/yyyy):

mm-dd-yyyy

Mother’s/Guardian’s Name:

First NameLast Name

Father’s/Guardian’s Name:

First NameLast Name

Mother’s/Guardian’s Home Phone Number:

(999)999-9999

Father’s/Guardian’s Home Phone Number:

(999)999-9999

Mother’s/Guardian’s Cell Phone Number:

(999)999-9999

Father’s/Guardian’s Cell Phone Number:

(999)999-9999

Mother’s/Guardian’s Email Address:

example@example.com

Father’s/Guardian’s Email Address:

example@example.com

Has either parent received a 4-year degree from a college or university?

Does your child participate in the free or reduced lunch program?

Is the child or his/her family homeless?

Is the child in foster care or a ward of the court?

Does the child have any special education needs?

If yes, please describe.

What is the total number of people living in the household (including parents/guardians)?

Do you (or your spouse) receive Public Assistance (TANF, AFDC, General Assistance, etc.)?

Do you (or your spouse) receive Social Security Payments (SSI, Disability, etc.)?

Parent/guardian, please select your total taxable income.

I certify that the annual income, source of income, current number in household and other information provided on this form is true and complete to the best of my knowledge.

Parent's/Guardian's Name

First NameLast Name

Parent's/Guardian's Signature

Date

mm-dd-yyyy