Broward College-Northeast High School-UB-Application Form

BROWARD COLLEGE UPWARD BOUND PROGRAM APPLICATION
The Broward College Upward Bound Program (BCUB) provides fundamental support to participants in their preparation for college entrance. The program provides opportunities for participants to succeed in their precollege performance and ultimately in their pursuit of post-secondary education. BCUB serves high school students at Deerfield Beach, McArthur, Northeast, and South Broward high schools, with a focus on students from families in which neither parent holds a bachelor's degree (first-generation college students). Upward Bound is a Federal TRIO Program governed by the United States Department of Education. Students who were not born in the United States must provide evidence of eligible legal immigration status in the U.S. before they may be considered for the Broward College TRIO Upward Bound Program.
- Student Name
  
  First NameMiddle InitialLast Name
- Broward County Public School (BCPS) Student ID Number
- High school you attend or will attend:
- Grade Level for the current school year as of August of (2023,2024,2025,2026,2027)?
- Student Mailing Street Address
  
  Street Address
  
  Apt. Number
  
  CityState
  
  Zip Code
- Student Cell Number
  (999)999-9999
- May we text you?
- Student E-mail (Gmail)
  example@example.com
- Date of Birth
  
  MonthDayYear
  mm-dd-yyyy
- Biological Sex
- Gender Identity
- Are you taking ESOL classes?
- What is your first language?
  
  Other
- Specify Chinese dialect:
- Ethnicity: Are you Hispanic/Latino?
- Race: Check all that apply. Must check at least one.
- What is your immigration status? Please note immigration documents must be provided.
  
  Other
- Permanent Resident #
- Permanent Resident Card Expiration Date
- Are you involved in any of the following programs? Check all that apply.
- How did you first learn about the TRIO Upward Bound Program?
  
  Other
- Name of individual:
- Have you previously applied for the TRIO Upward Bound Program?
- Check ONE box below that represents the highest level of education, that you the student, expects to complete:
- What was your grade point average (GPA) at the end of last semester?
- Have you earned passing scores for the FSA in the following subject matters? Select all that apply.
- Parent/Guardian Information
  
  Complete parent/guardian information for each parent/guardian in your household and any parent/guardian who provides financial support.
- Parent/Guardian 1 First Name
  
  First NameMiddle InitialLast Name
- Relationship to student:
  
  Other
- Did Parent/guardian 1 earn a four year (bachelor’s degree) from a college or university?
- Home Phone Number
  (999)999-9999
- Cell Phone Number
  (999)999-9999
- Work Phone Number
  (999)999-9999
- Employer
- Occupation
- Email
  example@example.com
- Please select the applicable:
- Parent/Guardian 2 First Name
  
  First NameMiddle InitialLast Name
- Relationship to student:
  
  Other
- Home Phone Number
  (999)999-9999
- Cell Phone Number
  (999)999-9999
- Work Phone Number
  (999)999-9999
- Email
  example@example.com
- Did Parent/guardian 2 earn a four year (bachelor’s degree) from a college or university?
- Income Information
- How many people are in your family? Include yourself, plus the number of dependent children (home or away at college) + any other dependent people in the household who receive more than half of their support from the head of the household.
- Did your family file a Federal Tax Return last year?
- What was your Household TAXABLE Income? Found on IRS Forms: Form 1040-Line 43; on Form 1040EZ-Line 6; Form 1040A-Line 27
- What was your approximate family income?
- - If selected, we will attend a parent/student interview. If admitted into BCUB, we will follow all requirements, including attending tutoring and workshops during the academic year and participating in a six-week summer program.
  - I attest that the information provided is true and accurate. I understand it will be used to determine the eligibility of my child in a federally funded program and that documentation may be requested.
- I authorize TRIO BCUB to:
  (a) record my likeness and voice on a video, audio, photographic, digital, electronic and any other device or medium;
  (b) Use my name in connection with these recordings; and
  (c) Use, reproduce, exhibit or distribute in any medium (including but not limited to, print publications, video tapes, CD-ROM, Internet, social media or any other medium) these recordings for any purpose that BC, and those acting pursuant to its authority, deem appropriate, including promotional or advertising efforts. I release BC and those acting pursuant to its authority from liability for any violation for any personal or proprietary right I may have in connection with such use. I understand that all such recordings, in whatever medium, shall remain the property of BC, and that I will not receive any compensation for the use of such recordings. I have read and fully understand the terms of this release.
- Authorization
- Parent/Guardian Signature
  
  Clear
- Date
  
  MonthDayYear
  mm-dd-yyyy
- Student Signature
  
  Clear
- Date
  
  MonthDayYear
  mm-dd-yyyy

BROWARD COLLEGE UPWARD BOUND PROGRAM APPLICATION