Upward Bound Application - Medgar Evers College - CUNY

Medgar Evers College’s
Upward Bound Program
Medgar Evers College
Upward Bound Program
Student Application
For questions or additional information, please contact us:
1534 Bedford Ave.
Brooklyn, NY 11225
718-804-8868
718-804-8832 (fax)
Our mailing Address:
1650 Bedford Ave.,
Eastern Parkway Campus
Brooklyn, NY 11225
Sean Anderson, Director Ydhelca A. Pérez, Coordinator
(718) 804-8869 718-804-8868
sanderson@mec.cuny.edu yperez@mec.cuny.edu
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Medgar Evers College’s
Upward Bound Program
Upward Bound Application Checklist
Please check the following boxes after you have completed each part of the application.
Student Section of the application
Parent Section of the application
A recommendation form from a Counselor OR
a teacher
Copy of 2009 Tax Returns
If you did not file taxes, please attach one of the following documents to
verify income
Copy of W-2 forms from 2009 or income from another governmental
source
A signed statement from the student’s parent/guardian regarding
family income
A signed financial aid application
What Happens Next?
1. After your complete application has been submitted, the staff will
review your application. (Reminder: you are responsible for making
sure your recommendation letter is returned with your application.)
2. If you meet the minimum criteria, you will be interviewed by the
Upward Bound Staff.
3. You will receive a letter from the Upward Bound Staff about the
status of your application.
IMPORTANT
Your application will not be evaluated until you submit all of the above
information to the Upward Bound Office.
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Name:
Mailing
Address
Medgar Evers College’s
Upward Bound Program
Student Section
Last Name First Name Middle Name
Street or P.O. Box City State Zip Code
Telephone Numbers:
Home Cell Work
Email Address: Gender: (circle) Male Female
Date of Birth: Social Security Number: Grade:
Ethnicity: (circle one) White-Non-Hispanic Black or African American
Hispanic or Latino Native Hawaiian or Other Pacific Islander
Asian American Indian/Alaskan Native
More than one race other _________________________________
Are you (check one): _____ U.S. citizen
_____ an eligible non-citizen (please provide a copy of immigration documentation
_____ Other
______ Non- U.S. citizen
Language(s) primarily spoken at home:
High School you are attending:
What is your current GPA?
Do you plan on attending college? (Circle one) Yes No Not Sure
What type of careers are you interested in?
1.
2.
3.
What colleges or universities are you interested in attending?
1.
2.
3.
This is to certify that all information by me is true and correct to the best of my knowledge. Furthermore, I give Medgar Evers
College’s Upward Bound Program permission to receive copies of my education record and other materials necessary for
participation in the program.
Signature of Student: ________________________________________________ Date: ____________________________________
Student Academic/Extracurricular Information Sheet
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Medgar Evers College’s
Upward Bound Program
Parent Section
Parent/Guardian Information
This section must be completed by the student’s parent/guardian. If you have any questions, call
the Medgar Evers College’s Upward Bound Program office at (718) 804-8868. Please complete
all blanks, to avoid processing delays.
Confidentiality of Information
No one is allowed to see the information you provide unless he/she is an employee of the Medgar
Evers College’s Upward Bound Program or otherwise authorized to see this information. All
information provided in this section is protected by the privacy act and is not specifically reported
to the federal government for U.S. Department of Education. However, the Department of
Education does have the authority to gather general statistical data about program participants in
order to improve and measure the success of the Upward Bound Program.
Father/ Male Guardian
Name:
Highest Education Level Completed
___ Elementary or Junior High School
___ High School or GED
___ Voc./ Technical School
___ Some College
___ Associate’s Degree
___ Completed Bachelors Degree
Employer’s Name:
______________________________
Occupation:
______________________________
Work Number:
______________________________
Parent/Guardian Marital Status
(circle one):
Married Divorced Separated
Unmarried Widowed Other
Are you currently receiving public
assistance: Yes ( ) No ( )
If yes please circle the following:
Welfare Social Security Unemployment
Compensation Retirement Other
Did you file federal tax return last year?
Yes ( ) No( )
If yes please check one:
( ) Joint ( ) Separate
What was the total taxable income shown on
that return? (After deduction/s)
$___________
Number of People in household
Adults: ______ Children: _____
I certify by signing below that all of the above information is correct and that any false or
misleading information may result in disqualification of the applicant.
Parent/Guardian Signature: ______________________ Date: ______/_______/______
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Medgar Evers College’s
Upward Bound Program
Parent Section
Parent/Guardian Information
This section must be completed by the student’s parent/guardian. If you have any questions, call
the Medgar Evers College’s Upward Bound Program office at (718) 804-8868. Please complete
all blanks, to avoid processing delays.
Confidentiality of Information
No one is allowed to see the information you provide unless he/she is an employee of the Medgar
Evers College’s Upward Bound Program or otherwise authorized to see this information. All
information provided in this section is protected by the privacy act and is not specifically reported
to the federal government for U.S. Department of Education. However, the Department of
Education does have the authority to gather general statistical data about program participants in
order to improve and measure the success of the Upward Bound Program.
Mother/Female Guardian
Name:
Highest Education Level Completed
___ Elementary or Junior High School
___ High School or GED
___ Voc./ Technical School
___ Some College
___ Associate’s Degree
___ Completed Bachelors Degree
Employer’s Name:
______________________________
Occupation:
______________________________
Work Number:
______________________________
Parent/Guardian Marital Status
(circle one):
Married Divorced Separated
Unmarried Widowed Other
Are you currently receiving public
assistance: Yes ( ) No ( )
If yes please circle the following:
Welfare Social Security Unemployment
Compensation Retirement Other
Did you file federal tax return last year?
Yes ( ) No( )
If yes please check one:
( ) Joint ( ) Separate
What was the total taxable income shown on
that return? (After deduction/s)
$___________
Number of People in household
Adults: ______ Children: _____
I certify by signing below that all of the above information is correct and that any false or
misleading information may result in disqualification of the applicant.
Parent/Guardian Signature: ______________________ Date: ______/_______/______
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Medgar Evers College’s
Upward Bound Program
Student Information Release Form
Permission to Release Information for:
________________________________________________________________
Student’s Name (Please Print)
I authorize Medgar Evers College’s Upward Bound Program and
_________________________________________ High School to release and
or/receive copies of my son’s /daughter’s academic records, including,
but not limited to transcripts, grade reports , test scores, evaluations,
attendance and medical records, disciplinary actions, and other records
necessary to for participation in the MEC Upward Bound Program. This
information may be used for any federal reports of the Upward Bound
Staff. This release is to be effective throughout my high school and
college career, and will be terminated only upon graduation or termination
from the Upward Bound Program at Medgar Evers College.
Student’s Signature________________________________________
Date___________________
Parent/Guardian Signature__________________________________
Date___________________
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Medgar Evers College’s
Upward Bound Program
Parent/Guardian Information
List all dependents (excluding applicant) living in the household.
Name Age Occupation
Name of person(s) living in the home other than dependents/and relationship:
Name: ________________________________
Relationship_____________________________
Name: _______________________________________
Relationship_____________________________
Name: _______________________________________
Relationship_____________________________
I certify by signing below that all of the above information is correct and that any false or
misleading information may result in disqualification of the applicant.
Parent/Guardian Signature: ________________________________
Date: ___/_______/______
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Medgar Evers College’s
Upward Bound Program
Authorization for Medical Treatment:
Student’s Name: ___________________________________________________
I ____________________________________, parent/guardian of the above
named student, hereby authorize the director of the Medgar Evers College’s
Upward Bound Program and authorized representatives, to furnish such minor
medical care as the above named student may require. Further permission for
emergency treatment, i.e., treatment in event of serious illness or the need for
hospitalization and/or major surgery, is granted, conditional upon understanding
that the Director will use all reasonable efforts to contact the emergency reference
(parent/guardian) named herein. Failure in such efforts, however, should not
prevent the Director from providing such emergency treatment under the care of
the physician(s) contacted by the college as may be necessary for the best interest
of the life of the above named student. I further understand and agree that Medgar
College’s Upward Bound Program is not legally, financially, or otherwise liable,
for such emergency treatment, except as provided for through the group medical
insurance plan, and then only in the event that the above named student has
contracted for same prior to any emergency treatment.
_____________________________ ___________________________
Name of family Insurance Company Health Insurance Policy Number
Parent/Guardian’s Signature: ________________________ Date ____________
Student’s Signature: _______________________________ Date ____________
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Medgar Evers College’s
Upward Bound Program
Notice of Disclaimer
I, the undersigned, in full recognition of the possible dangers and hazards
inherent in any student activity of the sort Medgar Evers College’s Upward
Bound Program normally conducts; do hereby agree to assume all the risk
and responsibilities surrounding my child’s participation in The Medgar
Evers Upward Bound Program activities. I further, hereby defend, hold
harmless, indemnify and release, and forever discharge the college, and all
its officers, agents, and employees from and against any and all claims,
demands and actions, or cause of action, on account of damage to personal
property, or personal injury, or death as a result of my child’s participation,
which may result from causes beyond the control of, and without the fault or
negligence of the college, its officers, agents, or employees, during the
period of my child’s participation aforementioned.
Signature of Parent/Guardian_____________________
Date_______________
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