VETERANS UPWARD BOUND PROGRAM APPLICATION FOR SERVICES

VETERANS UPWARD BOUND PROGRAM

Application for Services
Personal Information
Name

First Name Last Name
Social Security #
Date of Application

Month Day Year
Date
Address
City, State, Zip
Phone Number
Please enter a valid phone number.
Date of Birth

Month Day Year
Date
Sarpy

County Douglas Washington Dodge
Email Address
example@example.com
First and Last Name or Person Who is Always Able to Reach You
Phone Number of Person Who is Always Able to Reach You
Participant Demographics
Employment

unemployed full-time part-time retired
Gender

Male Female
Do you receive VA disability compensation

Yes No
Race (Check all that apply)

American Indian/Alaskan Native Black or African American Native Hawaiian or other Pacific Islander Asian White Hispanic/Latino?
Education
Have you completed High School?

H.S. Graduate G.E.D. Graduate Not completed
Date of Last Enrollment or the Year You Graduated from High School

Month Day Year
Date
Name of School Where You Were Last Enrolled
City and State (of School) Where You Were Last Enrolled
College
What is your highest level of college attainment?

I have a Bachelor's Degree I have an Associates Degree Currently Enrolled (Working toward a Degree) Some College (Not Currently Enrolled) I have never attended college
College, Degree Type, Program/Major (if you have never attended college or did not complete college enter "N/A" in the field.
Date of Last Enrollment

Month Day Year
Date
Do you have a defaulted student loan?

Yes No Unsure
What are your future education and career goals?
Military Service
Service (Check all that apply)

I served on active duty as a member of the Armed Forces of the United States for a period of more than 180 days. I served on active duty as a member of the Armed Forces of the United States and was discharged or released because of a service connected disability I was a member of a reserve component of the Armed Forces of the United States and was called to active duty for a I was a member of a reserve component of the Armed Forces of the United States who served on active duty in support of a contingency operation on or after September 11, 2001.
Branch of Service

Air Force Marine Corps Coast Guard Army Navy Reserve/NG
Military Discharge Type

Honorable General General Bad Conduct Dishonorable Other than Honorable
Date of most recent discharge

Month Day Year
Date
Are you eligible for G.I. Bill education benefits?

Yes No Not sure
Do you have a disability related to your military service?

Yes No
First Generation Status
Did either parent or guardian with whom you resided have a bachelor’s degree prior to you turning 18? *Please provide this information only for those parents/guardians living in your former household.
Mother/Female Guardian

Yes No
Father/Male Guardian

Yes No
Income
(Complete ONE of the two boxes below)

Complete this item if you DID file a tax return last year.

Complete this item if you were NOT required to file a tax return last year.
I filed an income tax return last year. The number of individuals currently living in my household and/or claimed as dependents (including myself) is
My total taxable income for last year was $ Form 1040 line 43 or Form 1040A line 27 Please note that taxable income is different from gross or net income.
I was not required to file a tax return last year. The number of individuals currently living in my household and/or claimed as dependents (including myself) is
My total non-taxable income for last year (from all sources) was
What Veterans Upward Bound Services are you most interested in?

Assessment of academic skills Development of an education or career plan Assessment of career interests Assistance with postsecondary school applications Math GED completion Science Assistance with financial aid and veterans Information about college degree plans and programs Foreign Language Referral to community/veterans’ agencies and supportive services Composition Cultural and social opportunities Literature Study skills Reading College visits/tours Computer Skills Financial Literacy
Citizenship

I am in the United States for other than a temporary purpose. Please provide evidence from the Immigration and Naturalization Service of your intent to become a permanent resident. I am a permanent resident of American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, U.S. Virgin Islands or the Trust Territory of the Pacific Islands. I am a resident of the Freely Associated States – the Federated States of Micronesia, The Republic of the Marshall Islands, or the Republic of Palau.
Are you a Citizen, National, or Permanent Resident of the United States?

Yes No
How Did You Hear About Veterans Upward?

Referral from community agency Referral from veterans' agency (VA, Vet Center) Advertisement Our website Referral from a school or educational institution Word of mouth/walk-in Referral from another TRIO project Referral from non-TRIO program Other
I would like to participate in the Veterans Upward Bound program and receive the free services provided. I hereby certify that the information provided in this application is accurate and complete to the best of my knowledge.
Signature

Clear
Date

Month Day Year
Date
Consent and Release Form
I HEREBY GIVE MY CONSENT FOR Metropolitan Community College or its agency to use my name, likeness, photograph and/or comments. I understand these will be used exclusively for the College without compensation, be it publications, advertising, television, film, radio, Internet or other appropriate communication or educational media. I sign this of my own free will.
Name

First Name Last Name
Date

Month Day Year
Date
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone
Email
example@example.com
Signature

Clear
Should be Empty:

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VETERANS UPWARD BOUND PROGRAM

Personal Information

Participant Demographics

Education

College

Military Service

First Generation Status

Income

Consent and Release Form