Mott Community College-Flint-UB-Application Form

Upward Bound Application for Admission
This application is for participation in the MCC Upward Bound Program. The MCC Upward Bound Program is a Federally Funded (program receives 100% of their funding from the Federal Government) for low-income, first generation and academically at-risk high school students serving the Beecher, Flint and Westwood Heights School Districts. The goal of the program is to provide support services to increase high school graduation rates and matriculation into post-secondary education.
1. Email
example@example.com
2. Student's Name

First NameLast Name
3. Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearmm-dd-yyyy
Student Information
4. Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
5. Student Cell Phone #
(999)999-9999
6. Student Email Address
example@example.com
7. Current School District (At time of application)
8. Current Grade
9. Current GPA
10. Student Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearmm-dd-yyyy
11. Student Gender

Other
12. Is the student a U.S. citizen? This does not disqualify the student from participation.
13. If no, what is your country of permanent residency?
14. The student lives with :
15. Student plans for education beyond high school?
16. Does the student have an Individualized Educational Plan (IEP) for a learning, physical, emotional, or mental disability? This does not disqualify students.

Other
17. If student has an IEP please describe.
18. Are you involved in any other Pre-College or after school program:

Other
Parent/Guardian Information
19. 1st Parent/Guardian Name

First NameLast Name
20. Relationship to student?
21. Lives in the home with student?

Other
22. Highest level of education completed
23. Current Occupation
24. Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
25. Parents Cell Phone Number
(999)999-9999
27. Parent Email Contact
example@example.com
28. I agree to be contacted by the UB Staff
29. Citizenship:

Other
Parent/Guardian Information Continued
30. Is there a second parent living in the home?
31. 2nd Parent/Guardian Name

First NameLast Name
32. Relationship to student?
33. Lives in the home with student?

Other
34. Highest level of education completed
35. Current Occupation
36. Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
37. Parents Cell Phone Number
(999)999-9999
38. Secondary/Emergency Number
(999)999-9999
39. Parent Email Contact
example@example.com
40. I agree to be contacted by the UB Staff
Medical Information & Emergency Contact

It is important that we are aware of any medical issues the student may have. MCC Upward Bound retains the right to request additional medical documentation or to duplicate the information for field trip permission slips and other applications to insure we have all of the important information necessary. The contact information is used in emergencies if the previous contacts do not work
41. Is there any medical information you feel is important for the Upward Bound staff to be aware of regarding your son/daughter (i.e., ongoing health issues, long-term medications, special diet, allergies to food or medication, etc.)?
42. Emergency Contact Name

First NameLast Name
43. Emergency Contact Phone Number
(999)999-9999
44. Relationship To Student
Parent Certification and Policies

To remind parents, and in accordance with government policies, Upward Bound is required to gather information concerning each member’s academic progress while in high school as well as enrollment status, financial aid assistance, and academic progress while in college. Additionally, a school transcript is necessary to determine eligibility for the program. The Family Education Rights and Privacy Act of 1974 makes it necessary for Upward Bound to obtain permission from a parent or guardian of a student who is under the age of 18 in order for educational institutions to release this information to Upward Bound.

Policy on Non-Discrimination

Mott Community College shall not discriminate against any person because of race, color, creed, religion, national origin, gender, age, disability, or sexual orientation. The college shall work for the elimination of improper discrimination in the areas listed above in (1) organizations recognized by the college, and (2) from non-University sources where students and employees of the college are involved.

Equal Opportunity Policy

Mott Community College admits students of either sex, and any race, color, or national or ethnic origin to all the rights, privileges, programs and activities accorded to students of the University. The college does not discriminate against students on the basis of sex, race, color, or national or ethnic origin in the administration of its educational policies, admissions policies, scholarships and loan programs, and athletic and other University-administered programs.

A caregiver's completion of this application also authorizes the school attended by the aforementioned student to release report cards, transcripts, and other information relating to academic progress to Mott Community College Upward Bound upon their request.

After entry into the program, MCC Upward Bound will need to verify parent income for student eligiblity. This could include a review of tax records from the previous years.
45. Additionally, I certify that all of the information provided on this application is true and correct to the best of my knowledge.
46. Please type your first and last name below to acknowledge your understanding of the policies above.
47. In order to admit a student into the program, an interview must be held. Because of the physical limitations involved in our government's response to the COVID-19 crisis, would you prefer to hold a virtual interview (using ZOOM software or Google Hangouts) or to have a conference call?

Other
48. Please list the best time(s) to contact you.

Parental Income Statement

Upward Bound is a program funded by the U.S. Department of Education. In order to insure that the MCC Upward Bound Program follows federal income guidelines we are asking you to fill out this form and provide income verification documentation with this application.
Name of Parent/Guardian

First NameLast Name
Address of Parent/Guardian

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Total number in household: How many people live in )Ollr household (include children away al college)?
Use your previous year tax return to complete the section below. Do not use the Adjusted Gross Income.
If you did not file a tax return skip to Question #3.
Total taxable income:$
(Please Check the Tax Form used to file your taxes.)

If you did not file income tax, please state your source(s) of income:

Rows	$
FIA
Child Support
Workers Compensation
Social Security
Pensions
Other

File Upload

Cancelof
Parent's/Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Upward Bound Application for Admission

Student Information

Parent/Guardian Information

Parent/Guardian Information Continued