Indian River State College-UB

St. Lucie County Upward Bound Program Application

Information on this form is confidential.
Upward Bound is a federally-funded, pre-college program designed to help motivated students develop the skills necessary for success in education beyond high school.

Upward Bound provides students in grades 9-12 with academic advisement, tutoring, career exploration, financial aid, scholarships, college admissions assistance, college tours and cultural events.

The ultimate goal of the Upward Bound Program is to assure that our participants graduate from high school, apply and enter the college of their choice, secure financial aid and scholarships to pay for their college education, and graduate with a postsecondary educational credential.

Part III: FAMILY/INCOME INFORMATION
With Whom Does The Applicant/Student Live? Check all that apply*

FatherMotherStepfatherStepmotherFoster Parent(s)Court Ordered Legal GuardianOther
Parent/Guardian #1
Name*

First NameLast Name
Relation*

MotherFatherStep-parentOther
Occupation*
Contact Number: Cell*
(999)999-9999
Work*
(999)999-9999
Email*
example@example.com
1st language*
Does parent/guardian speak English?*

YesNo
Highest level of education completed in USA*

Did NOT graduate from high schoolHS Diploma/GEDAssociateBachelorMasterDoctorate
Parent/Guardian #2
Name

First NameLast Name
Relation

MotherFatherStep-parentOther
Occupation
Contact Number: Cell
(999)999-9999
Work
(999)999-9999
Email
example@example.com
1st language
Does parent/guardian speak English?

YesNo
Highest level of education completed in USA

Did NOT graduate from high schoolHS Diploma/GEDAssociateBachelorMasterDoctorate
Which income tax form did the applicant's parent/legal guardian file last year?*

10401040EZ1040A-OR- Parent(s)/Guardian(s) DID NOT file income tax forms this past year.
(Attach signed copy of last year’s tax return)

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Family Income: $*
What is your family taxable income? Check only one. Taxable income information can be obtained from the 1040A tax return form - Line 15.

Less than or equal to $23,475Between $23,476 and $31,725Between $31,726 and $39,975Between $39,976 and $48,225Between $48,226 and $56,475Between $56,476 and $64,725Between $64,726 and $81,225More than $81,225

-AND- Received the following (check all that apply): Indicate the Annual Benefited Amount below AND attach copy of documentation

	(check all that apply)	$
Social Security
Welfare/A.F.D.C
Disability
Unemployment Insurance
Foster Child
Food Stamps
Veteran’s Benefits
Other (please explain below)

Family size (total number of people living in the household or supported by parent/guardian)*
I, the undersigned, declare under penalty of perjury that all the income reported on this application is true, complete, and accurate to the best of my knowledge.
Signature of Parent/Guardian*

Clear
Relationship to applicant *
Date*

MonthDayYear
mm-dd-yyyy
This information is protected by the Privacy Act. No one may see the information unless they work with, or for the Upward Bound Program, or are specifically authorized to see it.
Notification of Social Security Number Collection and Usage

Indian River State College is in compliance with FL Statute 119.071(5) regarding the collection and usage of Social Security numbers. Copies of the IRSC Notification of Social Security Number Collection and Usage document can be obtained from Student Services at all IRSC campuses and at the IRSC website at www.irsc.edu

Part IV: MEDICAL CONSENT FORM
Dear Parent or Guardian:

The IRSC Health and Wellness Center provides student health care services under the supervision of a registered nurse. It is necessary for you to sign this form for your child to receive student health care if he/she is under the age of 18. Your signature below authorizes the appropriate treatment for your child, which may include:
1. First Aid Care
2. Treatment of health problems (stomach aches, earaches, headaches, cuts, sores, colds, coughs, ringworms, etc.)
3. Minor Emergency Care
Indicate any special needs your child may have*
Your signature on the line below indicates your consent for treatment
Parent/Guardian*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Sign below if you DO NOT want the health team to provide any services to your child.
Parent/Guardian*

Clear
Date*

MonthDayYear
mm-dd-yyyy
If you have any questions, contact the IRSC Health and Wellness Center at (772) 462-7825.

Part V: RELEASE & AUTHORIZATION
RECORDS RELEASE

I authorize the release of school records for the applicant’s file that may be requested by Upward Bound at Indian River State College. I understand that the U.S. Department of Education funds Upward Bound and will use these records to provide academic advisement and other services. I also understand that these records will be handled in a confidential manner and that they will be made available only to program staff and representatives from Federal and State Departments of Education.

This authorization release includes, but is not limited to, the following records:
- Official School Transcript
- Student History File with test scores
- Academic History with test scores
- Basic Skills Test Results
- Attendance Record for 6th-12th grades
- Student grades/progress reports
- Information concerning disciplinary actions
- Test Results (PSAT, SAT, ACT, TABE, PERT, FCAT if available)
Note: A photocopy of this record release form should be accepted as an original and the date of the application has no bearing when the Indian River State College Upward Bound Program requests the information.

MEDICAL AUTHORIZATION

If medical services are needed by my son/daughter while participating in the Upward Bound program or on field trips, I give my permission for my son/daughter to receive any medical services deemed necessary.

ACTIVITY AND FIELD TRIP AUTHORIZATION/RELEASE

As the parent/guardian of the applicant, I do willingly execute this release in consideration of the educational benefit to be derived by my child in participating in Upward Bound, a College sponsored activity. I hereby release from liability and hold the College harmless from any and all claims and causes of action which might be brought by my child for loss of property, personal injury or death sustained by my child arising out of travel or activity conducted by or under the control of the College. I understand that the term “College” as used herein shall include the employees, administrators, agents, and Board of Trustees of the College.

PHOTO RELEASE

I hereby grant Indian River State College Upward Bound permission to photograph/video my son/daughter and/or to use their likeness in photograph(s)/video in any and all of its publications and in any and all other media, whether now known or hereafter existing, controlled by Indian River State College Upward Bound, in perpetuity, and for other uses by the College or Program. I will make no monetary or other claim against Indian River State College Upward Bound for the use of the photograph(s)/video.

By signing, I hereby acknowledge and certify that the information contained in this application, and any attached supporting documentation provided, is true and correct.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Applicant/Student Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy

ESSAY
“WHY YOU WANT TO BE AN UPWARD BOUNDER”

PLEASE NOTE: IF YOU ARE APPLYING, PLEASE ANSWER THE QUESTION BELOW. YOUR ANSWER SHOULD BE A MINIMUM OF 5 SENTENCES. THIS WILL HELP US GAIN A BETTER UNDERSTANDING OF YOUR ACADEMIC AND CAREER INTERESTS. IF YOU NEED ADDITIONAL SPACE, PLEASE ATTACH ADDITIONAL SHEET/S IN THE SPACE PROVIDED BELOW.
In the space below Explain: Why You Want to be an Upward Bound student.Identify the academic and/or personal areas and/or services in which youbelieve our program can benefit you.
Upload Additional page/s

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RECOMMENDATION
Counselor Name

First NameLast Name
Counselor Email
example@example.com
Teacher Name

First NameLast Name
Teacher Email
example@example.com
Teacher Name

First NameLast Name
Teacher Email
example@example.com