Southwestern Oregon Community College-UB-Application Form

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Citizenship:*

Citizen or national of the United StatesPermanent Resident of the United States

Please provide a copy of your alien registration of I-94 form:

Social Security Number:

999-99-9999

Legal Name:*

First NameMILast Name

Preferred Name:

Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone #:

(999)999-9999

Students Cell #:

(999)999-9999

Student email*

example@example.com

Gender:

FemaleMale

Preferred Pronouns:

Age:

Date of Birth:*

mm-dd-yyyy

T-Shirt size

Ethnicity:

A. Are you Hispanic/Latino:*

YesNo

B. Select all that apply:*

American Indian or Alaskan Native, non-Hispanic/LatinoAsian, non-Hispanic/LatinoBlack or African-American, non-Hispanic/LatinoWhite, non-Hispanic/LatinoNative Hawaiian or other Pacific Islander, non-Hispanic/LatinoTwo or more races, non-Hispanic/LatinoRace or Ethnicity Unknown

Are you a foster youth?*

YesNo

Are you a ward of the court?

YesNo

Please provide documentation:

If you said yes, please include your case worker contact information

School:*

MarshfieldNorth Bend

Grade in school:*

9th10th11th12th

Graduation Year:

Student Resides with:*

Parent/guardian 1

Name:*

First NameLast Name

Relationship:*

Occupation/Job Title:*

Contact Phone #:*

(999)999-9999

Email:*

example@example.com

Have you received a four-year degree from a college or university?*

YesNo

Check here if UB can send you text/email notifications:

Yes

Parent/guardian 2

Name:

First NameLast Name

Relationship:

Occupation/Job Title:

Contact Phone #:

(999)999-9999

Email:

example@example.com

Have you received a four-year degree from a college or university?

YesNo

Check here if UB can send you text/email notifications:

Check here if UB can send you text/email notifications

Parent(s) preferred language:

What primary language is spoken a home?

What is the TOTAL number of persons in your household?*

Please provide your family's total TAXABLE income (IMPORTANT - use the amount from 2022-IRS form 1040 line 15)*

Please provide your family's total TAXABLE income (IMPORTANT - use the amount from 2023-IRS form 1040 line 15)

(Note: Your TAXABLE income can be found on the federal income tax return you filed for the last calendar year. All IRS forms will have a separate line for the total TAXABLE income: do not confuse it with your total wages or your adjusted gross income.)

Special Circumstances:

I DID NOT file a Federal Income Tax Return for the last calendar year.I had no taxable income for the last calendar year (if you checked this option an additional form may be required)

My family's income was:

Parent/Guardian Signature:

Academic Status

Current Cumulative GPA:

Strong Academic Subjects:

Subjects Needing Tutoring Help:

Assessment of Student Need

In order to enroll in post-secondary education, I would benefit from the following services:*

Career InformationAcademic ImprovementCollege PreparationScholarships & Financial Aid Information

Medical Release: Should my student require medical attention while participating in UB activities and I cannot be contacted. I give my consent to medical examination and treatment deemed necessary by the attending medical professional.

Mandated Reporting: Most information shared between participants and Program Representatives is held completely confidential. Please be aware of the few exceptions. Information shared regarding abuse (physical, mental or sexual) and/or harm to oneself or others must be reported by law to the appropriate individuals.

FERPA Consent: I hereby give TRIO/UB Program staff permission to have access to grades, progress reports, school transcripts assessment test scores, school lunch program eligibility and updated contact information from school administration. I authorize TS to obtain information related to my child’s application for college admission and acceptance status, financial aid application (FAFSA) and award letter at any and all colleges and universities. I authorized the release of verifying placement and retention in college and/or employment after graduating high school to provide support with retention in college and employment.

Media Release: I hereby give permission to the TRIO/UB Program Staff to photograph my child for promotional purposes and/or file records related to the TRIO/UB Program and/or statements to the used by UB for promotion, publicity or instructional purposes.

Participation: I, as the parent and student agree to participate in TS activities. I, the student, agree to do well in high school and pursue post-secondary education and I, the parent, will support and encourage my child in these efforts.

In consideration of granting permission by the Upward Bound (UB) program for the above-named minor to participate in the activities sponsored by Southwestern Oregon Community College (SWOCC) UB. The participant, his/her parents(s) or legally appointed guardian hereby agree to indemnify, hold harmless, release and forever discharge the employees and/or agents from all claims and demands which the participant, his/her parent(s) or legal guardian or the representatives or successors of them or any person may have against SWOCC, its employees and agents by reason of acts, illness, injury or other consequences arising or resulting directly or indirectly from the participation of said minor in the aforementioned.

Note: All personal records or documentation will be held in strictest confidence by the staff of UB and SWOCC. (Consistent with the Federal Family Education Rights and Privacy Act of 1974, regulations and other laws). Personal records will not be released to any other entity without my prior acknowledgment and consent. This acknowledgement will be effective for the duration of my child’s participation in the program

By signing my name on the signature line, I certify that each response within the application is true and complete to the best of my knowledge. It also indicates that I acknowledge and give consent to the request of the UB Program.

I give permission for my son/daughter to be interviewed, photographed or videotaped by Upward Bound for use on radio, TV, in printed news media, or in program promotional materials (such as UB brochures)*

YesNo

Student Name (Please print name):*

First NameLast Name

Student Signature:*

Date:

mm-dd-yyyy

Parent/Guardian Name (Please print name):*

First NameLast Name

Parent/Guardian Signature:*

Date:

mm-dd-yyyy

Do you receive any of these benefits?

SNAPTANFSection 8 Housing

Southwestern Oregon Community College Upward Bound (UB) Application

Part 1-Eligibility Information

Part 2 - Parent Information

Part 3-Need for Academic Support

Part 4-Parent/Guardian Authorization