Gulf Coast State College-UB-2023 Application Form

Household Information
What is the total number of persons (including yourself) residing in your household (i.e., family unit)?*
What is the total number of persons (including yourself) residing in your household (i.e., family unit)?*
What is your family’s Taxable (not total) Income from the last calendar year? (Please mark one response only)*

$0 to $22,590$22,591 to $30,660$30,661 to $38,730$38,731 to $46,800$46,801 to $54,870$54,871 to $62,940$62,941 to $71,010$71,011 to $79,080More than $79,080
Note: taxable income (Adjusted Gross Income) can be found on the federal income tax return (IRS Form 1040, line 43; on IRS Form 1040A, line 27; IRS Form 1040EZ, line 6)

Please type your answers

	School/Program Type
Middle School
High School
High School Completion Program (e.g., GED)

Acknowledgments (please initial each statement)
I want to participate in GCSC’s TRiO Upward Bound program because I have a need for academic support to pursue successfully a program of education beyond high school.*
I authorize the release of my official academic records—such as transcripts, test results, attendance, grades, progress reports, disciplinary information, and Individual Education Plans (IEP)—to GCSC’s TRiO Upward Bound program and understand that the information in such records will be used only to assess my need for program services, discern my educational progress, evaluate the effectiveness of project activities, and fulfill reporting requirements*
I certify that all statements given in this application are true and accurate to the best of my knowledge.*
I permit TRiO to send me text messages at the number provided, including messages sent by auto-dialer, and I acknowledge that msg & data rates may apply*
I grant TRiO permission the use of my photograph–taken, for example, on various field trips or social events–and name in any GCSC publication, such as our website, newsletter, social media, or newspaper articles.*
Applicant Signature:*

Clear
Date:*

MonthDayYear
Date
Parent Signature:*

Clear
Date*

MonthDayYear
Date

Upward Bound Participant Application Fiscal Year 2024