Neosho County Community College-UB-Interest Form

NEOSHO COUNTY COMMUNITY COLLEGE UPWARD BOUND – INTEREST FORM
STUDENT INFORMATION

This section should be completed by the student. All information will be held in the strictest confidence. Missing or inaccurate information will delay the application's processing and affect ability to determine eligibility
Legal name:*

First NameMiddle NameLast Name
Address: *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Preferred Name:
Student Cell Phone: *
(999)999-9999
Student SCHOOL email:*
example@example.com
Student PERSONAL Gmail:*
example@example.com
Date Of Birth:*

MonthDayYear
mm-dd-yyyy
Current Age:*
Sex (M, F):*
Are you a US Citizen?*

YesNo
If no, are you a permanent US Resident?

YesNo
1. Race: Check one or more races (categories of origin)*

American Indian/Alaska Native (North/South America)Asian (Cambodia, China, India, Japan, Korea, Malaysia, Pakistan,Philippine Islands, Thailand, Vietnam, etc.)Black/African American (Black racial groups of Africa)Native Hawaiian/Pacific Islander (Hawaii, Guam, Samoa, or other Pacific Islands)White (Europe, the Middle East, or North Africa)
2. Ethnicity: Is the student Hispanic/Latino?["Hispanic/Latino" refers to a person of Cuban,Mexican, Puerto Rican, South or Central American, or other Spanish culture/origin,regardless of race. People of Hispanic origin may be of any race(s).]*

YesNo
EDUCATION INFORMATION
What school do you attend? *
What grade are you in? (Circle one)*

9101112
Do you have an Individualized Education Program (IEP) or a 504 Plan?*

YesNo
Are you currently in an Educational Talent Search or a GEAR UP program? Circle all that apply.*

Educational Talent SearchGEAR UPBothNeitherUnsure
Power School Information: Username*
Power School Information: Password *
Overall GPA:_*

Please list your courses and current grade in each class as they appear in PowerSchool: *

Rows	Course	Grade/%
1.
2.
3.
4.
5.
6.
7.
8.

FAMILY INFORMATION

This section must be completed and signed by the student’s parent(s)/guardian(s). All information will be held in the strictest confidence. Missing or inaccurate information will delay the application's processing and affect ability to determine eligibility.
Guardian/Parent 1 in Household
Name:*

First NameLast Name
Employer:*
Cell Phone:*
(999)999-9999
Email Address:*
example@example.com
Are you a US Citizen?*

YesNo
Education: (Highest Level Completed)*

Less than High School GraduateHigh School GraduateSome CollegeBachelor’s degree or Higher
If you do not have a four-year college degree, would you like information on pursuing a degree?*

YesNo
Is there another Parent/Guardian in your household?

YesNo
Guardian/Parent 2 in Household
Name:*

First NameLast Name
Employer:*
Cell Phone:*
(999)999-9999
Email Address:*
example@example.com
Are you a US Citizen?*

YesNo
Education: (Highest Level Completed)*

Less than High School GraduateHigh School GraduateSome CollegeBachelor’s degree or Higher
If you do not have a four-year college degree, would you like information on pursuing a degree?*

YesNo
Parents'/Guardians' Marital Status*

Single/UnmarriedMarriedMother DeceasedFather DeceasedFoster ParentsDivorcedLegally SeparatedSingle Parent HomeOther

Please list below the names of ALL persons living in your household (including the student), their ages, and their relationship to the student.*

Rows	Name	Age	Relation to Student
1
2
3
4
5
6
7

CONFIDENTIAL FAMILY INCOME INFORMATION
NCCC Upward Bound is a federally funded program, and government regulations require verification of family income as part of the application/admission process. This information could also be helpful in assisting your student with information about financial aid, scholarship opportunities, and special programs. Please check your annual TAXABLE INCOME (Line 15 on the 1040 tax form) or attach a copy of your most recent tax return. PLEASE DO NOT LIST YOUR GROSS (TOTAL) INCOME. (2026 Income Levels)
TAXABLE INCOME*

$0 - $23,940$23,941 - $32,460$32,461 - $40,980$40,981 - $49,500$49,501 - $58,020$58,021 - $66,540$66,541 - $75,060$75,061 - $83,580$83,581 or more
Is the student in Foster Care?*

YesNo
How many people live in your household, including yourself?*
Are you on any public assistance (AFDC, TANF, WIC, Food Stamps, SSI, etc.)*

YesNo
I certify that the above information is accurate and complete to the best of my knowledge.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
If you have questions or want to provide more information, contact us at ncccub@gmail.com or 620-432-0367.

NEOSHO COUNTY COMMUNITY COLLEGE UPWARD BOUND – INTEREST FORM

STUDENT INFORMATION

EDUCATION INFORMATION

FAMILY INFORMATION

CONFIDENTIAL FAMILY INCOME INFORMATION