FRC TRiO Upward Bound Application

Feather River College

570 Golden Eagle Ave.

Quincy CA, 95971

(530) 283-0202 ext. 266

FAX (530) 283-3890

Upward Bound is a free program that provides fundamental support to high school participants in their preparation for college entrance. The goal of Upward Bound is to increase the rate at which participants successfully graduate from high school and earn a college degree.
Legal Name

First NameMiddle NameLast Name
Home Address

Home Address

Street Address Line 2

CityState

Postal / Zip Code
Mailing Address

Mailing Address

Street Address Line 2

CityState

Zip
Home Phone #
Student Cell #
Please enter a valid phone number.
Student Email Address
example@example.com
Date of Birth

MonthDayYear
Date
Age
Sex

MaleFemaleNon-binary
School Attending
City of School
Grade Level
Race/Ethnic Background:
Do you identify as Hispanic/Latino

YesNo
What is your race/ethnicity (please check all that apply

American Indian/Native AmericanAsianBlack/African AmericanWhite/CaucasianNative Hawaiian/Pacific Islander
Primary Residence

ParentsFoster HomeSomeone other than legal GuardianLeagl Guardian (relationship)
Are you an emancipated minor (independent from parents)

NoYes
What is the primary language used in your home?
Do you have a documented disability

YesNo
Parent Statement of Agreement:

I agree to support my child in his/her endeavors for academic success. I agree to encourage his/her active participation in the Upward Bound Program.lagree to monitor the progress of my child. I agree to call the office at 530-283-0202 ext.266, if have questions about a scheduled Upward Bound activities. I agree that it is pertinent that my child not only participate during the academic year, but also participate inthe summer component of Upward Bound.

Participation Partnership Agreement:

Students participating in Upward Bound agree to commit themselves to the goals of graduating from high school and continuing in a post-secondary educational program. All of the following are expected:

- I agree to observe the rules and regulations of Upward Bound and my school district.

- I agree to participate in the Upward Bound 6-week summer program.

- I agree to attend lunch meetings, tutoring and special activities during the academic year.

- I agree to strive to achieve satisfactory academic progress in all classes and to maintain at least a 2.5 GPA.

- I agree to exhibit positive, friendly, cooperative and respectful behavior toward Upward Bound staff and student participants.

- I agree to provide proof of application for admission to a post-secondary education institution before graduating from high school.

- I agree to maintain communication with Upward Bound for six years after graduating from high school to report my academic progress towards a college degree.
Parent/Guardian's Signature

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Student's Signature

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PARENT INFORMATION, ELIGIBILITY AND CERTIFICATION

To Parent or Legal Guardian:

The personal information that you give to the Upward Bound Program is for the U.S. Dept. of Education.The information is protected by the Privacy Act. No one may see the information unless they work with or for the Upward Bound Program or are specifically authorized to see it. The information is necessary to determine if your child is eligible to participate in the Upward Bound Program and helps the U.S. Dept. of Education to measure his/her success. The U.S. Dept. of Education has the authority to gather such information (20 USC 1231a). Your child is not eligible for any services from the Upward Bound Program unless the information is given.
Mother's Information
Name
Mother's email address
example@example.com
Address
Occupation
Employer
Cell #
Please enter a valid phone number.
Home #
Please enter a valid phone number.
Work #
Please enter a valid phone number.
Highest Grade Completed by Natural or Adoptive Mother

UnknownElementaryHigh SchoolSome CollegeReceived 4-year degree (Bachelor's Degree)
Fathers Information
Name
Father's email address
example@example.com
Address
Occupation
Employer
Cell #
Please enter a valid phone number.
Home #
Please enter a valid phone number.
Work #
Please enter a valid phone number.
Highest Grade Completed by Natural or Adoptive Father

UnknownElementaryHigh SchoolSome CollegeReceived 4-year degree
Guardian/Step Parent Information
Name
Guardian/Step Parent email address
example@example.com
Address
Occupation
Employer
Home #
Please enter a valid phone number.
Work #
Please enter a valid phone number.
Cell #
Please enter a valid phone number.
Highest Grade Completed by Guardian/Step Parent

UnknownElementaryHigh SchoolSome CollegeReceived 4-year degree (Bachelor's degree)
With Whom does the applicant Live?

MotherFatherBoth Mother & FatherOther (specify)
Who financially supports the applicant?

MotherFatherBoth Mother & FatherOther (specify)
Is the applicant a (select one)

U.S. CitizenEligible Non-Citizen #:
Country of Birth
What was your family's most recent Taxable Income? Your TAXABLE income is less than your adjusted gross income and can be found on line 15 of your federal tax return. If possible, please attach a SIGNED COPY of your most recent federal tax
Taxable Income
If you had no Taxable income Please Write Zero
Tax Year
I had no Taxable Income
Number of persons supported by this income
including parent(s) and/or guardian(s)
I certify that all the information (provided by my child or me) contained in this applicationis true and correct.
Parent/Guardian Signature

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FEATHER RIVER COMMUNITY COLLEGE DISTRICT - UPWARD BOUND

SCHOOL RECORDS, TRANSPORTATION, PHOTO, INTERNET & MEDICAL RELEASE
Student Name
In order to obtain, exchange, and report information regarding participation in the Upward Bound program, I grant Upward Bound permission to obtain school records, transcripts, grade reports, and test results. I also grant the Upward Bound staff permission to speak with teachers, counselors, advisors and other school administrators at the participant's high school (and Feather River College if taking college courses) for the same purposes.
Parent's Signature

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Student's Signature

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I authorize and permit my student to participate in field trips, activities, and events sponsored & conducted by the Upward Bound Program. I understand that my child may be leaving his/her high school campus and/or Feather River Community College District campus and be transported by the Upward Bound staff in Feather River Community College District vans/buses and/or other authorized transportation systems (PUSD, PCS and/or Plumas Transit). I agree that Feather River Community College District, Upward Bound, and anyone associated with the college will not be held liable for any loss, injury, or death related to any field trip, activity or event. Furthermore, I agree to hold Feather River Community College District and its Board of Directors, administration, staff, and volunteers harmless from any claims whatsoever occasioned in any of the situations that I have agreed that Feather River Community College District shall not be liable.
Parent's Signature

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I grant permission to Upward Bound to take and use visual/audio images of my child. Visual/audio images are any type of recording, including photographs, digital images, drawings, renderings, voices, sounds, video recordings, audio clips or accompanying written descriptions. The images may be used in Upward Bound promotional materials without notifying me, such as FRC-sponsored web sites, newsletters, brochures, broadcasts, advertisements, newspaper articles and posters. I waive any right to inspect or approve the finished images or any printed or electronic matter that may be used with them.
Parent's Signature

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I grant permission for my child to access networked computer services such as Internet, World Wide Web, and electronic mail for instructional purposes.
Parent's Signature

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In the event that my child is involved in a medical emergency, I authorize the Upward Bound staff of Feather River Community College District to make decisions regarding immediate medical attention (hospitalization, administration of prescribed medications, doctor treatment, etc if am unable to be contacted or reached for verbal authorization.

Please provide facts concerning your student's medical history including allergies, medications, and any physical impairment to which a physician may be alerted:
Conditions/Allergies
Medications
Insurance Name & Number
Parent's Signature

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Feather River College

Upward Bound Short Essay Questions

The following questions should be answered in short, well-organized paragraphs.
What do you expect from the Upward Bound program?
What do you want out of life? What are your goals?
What are your thoughts about attending college after high school? Why?
What do you see as the most important event in your life so far? Why?
Please write a descriptive paragraph regarding where you see yourself in five years.
Name of Student Applying
Grade
Name of Teacher/Counselor for recommendation
Should be Empty:

Race/Ethnic Background:

Mother's Information

Fathers Information

Guardian/Step Parent Information

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