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).

    • Section A: Personal & Demographic Information: 
    • Are you a US Citizen?*
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    • Birth Date*
       - -
    • Gender*
    • Grade level at the time of this application*
    • High School*
    • Ethnic Identity*
    • SECTION B: Eligibility 
    • Please check or circle ALL that apply:*
    • Rows
    • Are you (the student) a disconnected or foster youth?*
    • DO YOUR PARENTS receive Social Security Benefits*
    • DO YOUR PARENTS CalWORKs/AFDC/EBT?*
    • DID YOUR PARENTS file a Federal Tax Return?*

    • 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.

    • Clear
    • Date*
       - -
    • Student Questionnaire 

    • Please Answer Each Question

    • Are you interested in a math and science career?
    • 8. Which High School will you be attending/are you currently attending?*
    • 6. Are you willing and able to participate in the upcoming 6-week Summer Program? (All new students to the Upward Bound program are expected to participate in the next upcoming 6-week summer program. Please plan to join us!)*
    • 7. I have access to the following (check all that apply):*
    • 8. What is your T-Shirt size (Upward Bound T-shirts are given to students during the Summer Program)?*
    • 9. Are you able to attend the following: a) After school tutorial sessions?*
    • 10. Are you able to attend the following: b) Saturday Program/field trips?*
    • Parent Questionnaire 
    • 1. Why do you want your son/daughter to participate in Upward Bound? (Select all that apply)*
    • 2. Are you willing to commit your effort to encourage and support your child’s active attendance in Upward Bound activities such as after school tutoring, Saturday workshops, and occasional field trips?*
    • 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.

    • Clear
    • Date*
       - -
    • Health History Form and Emergency Authorization form  
    • Grade level
    • Date of last medical examination
       - -
    • Have you had a serious illness or operation in the past?
    • Have you had a recent exposure to any contagious disease?
    • Have you ever had or still have one of the following illnesses:
    • Are you Vaccinated against Covid-19 (1 shot of J&J, or 2 shots of Pzfizer or Moderna)?
    • Are you allergic to: plants, foods, insect bites, any medications*
    • Date of last tetanus Injection (if known)
       - -
    • Are you taking any prescribed medications (pills, inhalers, etc.)? *
    • Type (please circle): *
    • Type (please circle): *

    • MEDICAL RELEASE TO BE SIGNED BY PARENT/GUARDIAN:

      Should {name127}  require medical attention and/or care while participating in the Fresno City College Upward Bound Program, I give my consent to medical examinations and necessary treatment, including drugs and X-rays, as may be deemed advisable by the attending physician.  This consent shall be effective so long as he/she is participating in the Upward Bound Program.  Should an emergency arise which requires major surgical procedures, Upward Bound staff will attempt to reach me and be guided by my wishes.  In the event that I cannot be contacted, the attending physician has my consent to act as medical judgment may dictate.

    • Date*
       - -
    • Clear
    • Income Verification Forms 
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    • Fresno City College

      Upward Bound (UB)
      Letter of Income Verification
      Please print

    • Date:
       - -

    • 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).

      Federal TRIO Programs Current-Year Low-Income Levels

      (Effective January 15, 2025 until further notice)

      1 $23,475
      2 $31,725
      3 $39,975
      4 $48,225
      5 $56,475
      6 $64,725
      7 $72,975
      8 $81,225

      The term "low-income individual" means an individual whose family's taxable income for the preceding year did not exceed 150 percent of the poverty level amount.

      The figures shown under family income represent amounts equal to 150 percent of the family income levels established by the Census Bureau for determining poverty status. The 2025 poverty guidelines are in effect as of January 15, 2025. Federal Register notice was published January 17, 2025.

    • Clear

    • Autobiography

    • 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.

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