Fresno City College-UBMS-Application Form

FRESNO CITY COLLEGE UPWARD BOUND MATH AND SCIENCE PROGRAM APPLICATION

1101 E. University Ave. Fresno, CA 93741 Phone (559)-443-8593 triobub@fresnocitycollege.edu
COMPLETE AND RETURN ALL ITEMS 1 THROUGH 8

1. Upward Bound Application
2. Student Questionnaire
3. Parent Questionnaire
4. Parent/Guardian Consent Form
5. Health History Form (please complete both sides)
6. Verification of Income

Please read the application carefully and ensure that all blanks are appropriately filled and signed.

If the application is submitted incomplete, processing will be delayed. If you have any questions, please call the Upward Bound Office at 559-443-8593

(Hmong and Spanish speakers available!!!)

Fresno City College (FCC) is a college of the State Center community College District.This institution does not discriminate on the basis of race, sex, handicap, religion, or age. All Upward Bound records are confidential and secured in accordance with the Family Educational Rights & Privacy Ace (FERPA).
Name*

First NameMiddle NameLast Name

SECTION B: Eligibility
Please check or circle ALL that apply:*

First Generation (Parents did NOT graduate from a 4 year college)Low IncomeBoth First Generation and Low Income

Please list ALL persons, (including yourself) living in your household: *

	Name	Relationship to Applicant
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Total family members*
Are you (the student) a disconnected or foster youth?*

YesNo
DO YOUR PARENTS receive Social Security Benefits*

YesNo
DO YOUR PARENTS CalWORKs/AFDC/EBT?*

YesNo
DID YOUR PARENTS file a Federal Tax Return?*

YesNo
PLEASE NOTE: FCC Upward Bound requires ONE of the following forms of financial verification to be included along with your completed application:

1) A signed statement identifying the parent(s) family size AND income level OR

2) Verification of family income from a government source CalWORKs, EBT, etc. OR

3) A SIGNED United states income tax return.

PLEASE contact us if further clarification is required.

HMONG AND SPANISH speakers available for translation.

BY SIGNING BELOW I HEREBY CERTIFY THAT THE INFORMATION ON THIS FORM IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
Parent/Legal Guardian’s Name *

First NameLast Name
Parent/Legal Guardian’s Name (Sign) *

Clear
Date*

MonthDayYear
mm-dd-yyyy

Parent/Guardian Consent Form
As part of the Upward Bound Program and its curriculum, there will be advising services available to my child.

Personal advising can take the form of individual/group meetings, presentations, guest speakers, field trips, educational films/videos, or interactive activities, which may require expression of feelings and sharing opinions.

I understand that as parent/guardian:

1. My child’s high school or middle school has my permission to release to the Fresno City College Upward Bound Program relevant and applicable information concerning my child (transcripts, attendance reports, etc).

2. Fresno City College is mandated to report CHILD ABUSE to the authorities.

3. My child has my permission to participate in field trips planned for and supervised by the Fresno City College Upward Bound Program. The program, the college, and the employees of Upward Bound are released by me from claims against them arising from injuries which might occur in route to/at the destination.

4. I agree to provide the Fresno City College Upward Bound program with a physical copy of my child’s social security card for matters pertaining to program eligibility, stipends, and internships, when needed.

5. Any medication taken during field trips, over night stays, and the summer program must be check in with Upward Bound staff with all instructions fully explained and signed by parents. NO medication can be given without written or verbal permission from the parent

I, the undersigned, declare under penalty of perjury that all information reported on this application is true to the best of my knowledge.
Parent or Guardian Name *

First NameLast Name
Parent or Guardian Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy

Income Verification Forms
Please upload your financial documents. Accepted documents include: 1040 Tax return for current year, or previous year, need pages 1 and 2. OR a statement of EBT benefits. OR a hand written letter listing number of family in household, income for current or previous year, dated, and signed by parent/guardian.

Cancelof
Certificates, Transcripts, Class Schedules, etc. (optional)

Cancelof
Fresno City College

Upward Bound (UB)
Letter of Income Verification
Please print
Student Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student ID#:
Email:
example@example.com
Date:

MonthDayYear
mm-dd-yyyy
Parent Name

First NameLast Name
# of people in our household
Income for the household last year
$

Parent/Guardian Verification
As the parent or guardian of the student listed above, I, {parentName} verify that there are {Of} people in our household last year was ${incomeFor} (see chart below).

1	$22,590
2	$30,660
3	$38,730
4	$46,800
5	$54,870
6	$62,940
7	$71,010
8	$79,080

U.S. Department of Education Low Income Levels (2023)

Parent/Guardian Name:

First NameLast Name
Parent/Guardian Signature:

Clear
Autobiography
In your autobiography, please include information you fell will assist us in learning more about you, your interests, and your needs. Include such things as: your birthplace, where you grew up, why you want to participate in the Upward Bound or Upward Bound Math & Science Programs, how UB/UBMS can assist you, which services you can benefit from, and your goals in life. Tell us what your educational goals are after high school such as: colleges, vocational or training majors and careers/occupations (please attach additional lined paper if needed).
Will do at another time

Will do at another time
Verification of Income
a.    PLEASE NOTE: FCC Upward Bound requires ONE of the following forms of financial verification to be included along with your completed application

1)      Verification of benefits from a government source CalWORKs, EBT, etc.

OR

2)    A SIGNED United states income tax return from the previous year.

OR

3)    SIGN a statement verifying income level and family size for previous year (please contact the FCC Upward Bound Program for form).

AMONG AND SPANISH speakers available for translation and clarification.

FRESNO CITY COLLEGE UPWARD BOUND MATH AND SCIENCE PROGRAM APPLICATION