Kansas City Kansas Community College-UB-Application Form

KCKCC Upward Bound Application

KCKCC Upward Bound Academy
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To apply for admission to the KCKCC Upward Bound Academy:
- Complete the following 7-page application
- Provide proof of income (copy of income tax)
- Complete the one-page statement (see page 6) explaining why you would like to join the UBA program
- The recommendation form (page 7) should be completed by a teacher, counselor, mentor, or community leader
- Contact the Upward Bound Academy Team at 913-288-7483 for further information or assistance
All answers must be written in English
Program Application

Upward Bound Academy
Full Name:*

First NameM.I.Last Name
Email:*
example@example.com
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone:
(999)999-9999
Social Security Number:
999-99-9999
Racial or Ethnic Group (Check all that Apply)

American Indian/AlaskanAsian/Pacific IslanderBlack/African AmericanHispanic/LatinoWhite/CaucasianOther
Gender:

MaleFemaleOther
Pronouns:
Age:
Birthdate:

MonthDayYear
mm-dd-yyyy
Are you a U.S. Citizen?

YesNo
If no, are you a permanent resident?

YesNo
If not a permanent resident, you must present evidence of your status
Are you a student with a disability on an Individual Education Plan (IEP) or 504 Plan who receives accommodations from your high school?

YesNo
If yes, explain:
Are you employed?

YesNo
If yes, how many hours do you work weekly?
School Information
Current School:
Expected High School (if different than current):
School Counselor:

First NameLast Name
Expected HS Graduation Month/Year:

MonthDayYear
mm-dd-yyyy
Current Grade:
Current GPA:
How many high school credits have you earned?
Have you failed any subjects?

YesNo
If yes, please list the subject(s):
Do you participate in any of the following services at your school?

Math labReading/Writing labESL programTutoringOther
Are you having difficulty in any classes?

YesNo
What are your current grades in the following subjects?
English:
Math:
Science:
History:
Family Information
Mother (Or Legal Guardian) Name:

First NameLast Name
Work Telephone Number:
(999)999-9999
Cell Number:
(999)999-9999
Email Address:
example@example.com
Highest Grade Level Completed:
Father (Or Legal Guardian) Name:

First NameLast Name
Work Telephone Number:
(999)999-9999
Cell Number:
(999)999-9999
Email Address:
example@example.com
Highest Grade Level Completed:
With whom do you live?

MotherFatherBothSelfGuardian
Total number of family members at home (self included):
Household yearly income:
Have either of your parents received a four-year (bachelors) degree?

MotherFatherNeither
Emergency Contact Person:

First NameLast Name
Relationship:
Phone:
(999)999-9999
Authorization
I understand the goals, objectives and requirements of the Upward Bound Academy program and agree to fulfill them. I also understand that if I do not fulfill the required goals and objectives, I will be dismissed from the program. I certify that all the information I have provided is valid and correct to the best of my knowledge.
Student Signature:

Clear
Date:

MonthDayYear
mm-dd-yyyy
I understand the goals, objectives and requirements of the Upward Bound Academy program and agree to support my child in fulfilling them. I also understand that if my child does not fulfill the required goals and objectives, he/she will be dismissed from the program. I certify that all the information I have provided is valid and correct to the best of my knowledge.
Parent/Guardian Signature:

Clear
Date:

MonthDayYear
mm-dd-yyyy
Family \Financial Statement
To be completed by parent/guardian

One of the criteria for admission is meeting the income guidelines established by the U.S. Department of Education. Before we can determine eligibility, please answer the following questions, and attach a copy of your most recent income tax return or medical card.

This information is strictly confidential and will be maintained in the UB office in accordance with the general education provision act (which outlines privacy rights of parents and students).
Family Income
1.) Did you file an income tax return last year?

YesNo
2.) Gross family income (before taxes and other withholdings) for last year:
$
3.) Adjusted gross income:
$
4.) Which of the following was the source of the above information? (check all that apply):

Father's employmentMother's employmentTANFSocial SecurityOther Income:
Father's occupation:
Mother's Occupation:
TANF amount per month:
Social Security amount per/month:
Are you eligible for veteran's benefits?

YesNo
If so, what kind?
5.) How many dependents were claimed on your income tax form last year?
Total number of persons living in household (including self):
6.) Foster child, list the child's monthly personal use income:
7.) Is the student a U.S. Citizen?

YesNo
What are your major concerns involving your student's education plans? (Please check all that apply):

How to pay for collegeHow to apply for collegeHelping them be academically preparedHelping them be socially preparedDeciding where they should goOther
I certify that all the informtion on this form is valid and correct to the best of my knowledge.
Parent/Guardian Signature:

Clear
Date:

MonthDayYear
mm-dd-yyyy
Insurance Provider
To be completed by parent/guardian
Student's Name:

First NameLast Name
Parent's Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone:
(999)999-9999
Work Phone :
(999)999-9999
Cell Phone:
(999)999-9999
Emergency Contact Person:

First NameLast Name
Phone:
(999)999-9999
Is the student covered by health insurance?

YesNo
Insurance Company:
Policy Type:
Policy Number:
Expiration Date:

MonthDayYear
mm-dd-yyyy
Please attach a front and back copy of the insurance card, including those covered through Kansas Medicaid or KS Kancare.

Cancelof
Medical Provider
I authorize the Upward Bound Academy program to provide emergency medical and dental services for my child. I will not in any way hold Kansas City Kansas Community College or the UB program responsible for any treatment deemed necessary for medical/dental services.
Parent/Guardian Signature:

Clear
Date:

MonthDayYear
mm-dd-yyyy
Parental Release for Student Travel
I authorize the Upward Bound Academy program to provide transportation for my child to program activities. I hereby release the UBA program from any responsibility for any criminal act of malice, vandalism, theft, and any other unlawful behavior during his/her trips sponsored by the UBA program.
Parent/Guardian Signature:

Clear
Date:

MonthDayYear
mm-dd-yyyy
Authorization for Release of Records
Student Name:

First NameLast Name
Date of Birth:

MonthDayYear
mm-dd-yyyy
DIRECTIONS: This form must be completed by the student and the parent/guardian.

The U.S. Department of Education requires that the Upward Bound Academy Program at Kansas City Kansas Community College follow and monitor the academic progress of students participating in UB by tracking secondary school graduation, college matriculation, persistence, and subsequent college graduation, etc.

In consideration of {studentName} being accepted for participation in the Upward Bound Academy program at Kansas City Kansas Community College, I/we hereby specifically authorize all secondary and post-secondary institutions attended by {studentName} to release the following information to representatives of the Upward Bound Academy program at Kansas City Kansas Community College.

Secondary Schools:
- Achievement, aptitude proficiency, state assessments, and interest scores (ACT, PACT, SAT, PSAT, Iowa Test of Basic Skills scores and all other tests taken since 7th grade)
- Official transcripts
- Official copies of report cards
- Activities chart or lists of extra- or co-curricular activities
- Family background data
- Interview information from school administration, counselors, and teachers  Health Related information during the summer non- residential program.
Post-Secondary Schools:
- Enrollment verification information
- Transcripts or transcript information documenting academic progress
- Degree attainment information
- Interview information from school administrators
This permission is granted for a period not to exceed ten (10) years after secondary school graduation or until this authorization is specifically cancelled by both {studentName} and his/her parent or guardian.

As a result of signing this form, the student applicant and his/her parent/guardian certify that they are providing this authorization with full understanding and voluntarily in consideration of the student applicant’s participation in the Upward Bound Academy program at Kansas City Kansas Community College and to permit the program to fulfill requirements imposed by the U.S. Department of Education, the funding agency.
Student Name Printed:

First NameLast Name
Date:

MonthDayYear
mm-dd-yyyy
Student Signature:

Clear
Date:

MonthDayYear
mm-dd-yyyy
Parent or Guardian Name:

First NameLast Name
Date:

MonthDayYear
mm-dd-yyyy
Parent or Guardian Signature:

Clear
Date:

MonthDayYear
mm-dd-yyyy
NOTE: Information obtained by this form shall not be transferred to any other person or agency than that listed above without the consent of the person whose signature appears here on.

SCHOOLS: Current school may retain copy of this form for student file.
Personal Statement
Student's Name:

First NameLast Name
Please address the following items in a one-page essay "Why I Want to be in Upward Bound?"
- What type of education do you plan to pursue after high school?
- What post-secondary institutions are you interested in attending?
- What careers are you interested in?
- What are your career goals and how do you plan to reach them?
- Why is education important to you?
Please print neatly to ensure that we can read your essay, or type and attach your essay to this sheet. If you attach your essay, please be sure to include your name and school at the top of the attached essay.
Type essay here:
Attach essay here:

Cancelof

KCKCC Upward Bound Application

Program Application

School Information

Family Information

Authorization

Family \Financial Statement

Insurance Provider

Medical Provider

Parental Release for Student Travel

Authorization for Release of Records

Personal Statement