Oklahoma City Community College Upward Bound
7777 S. May Avenue
Oklahoma City, OK 73159
Phone: (405)682-7865 Fax: (405)682-7815
Please print and complete in ink:
STUDENT’S NAME: ________________________________________ TODAY’S DATE: ________________________
First Name MI Last Name Month/Day/Year
ADDRESS: _________________________________________________________________________________________
Street Address or P.O. Box City State Zip Code
HOME PHONE: (_______) ____________________________ PARENT’S CELL PHONE: (______)_____________________
STUDENT’S CELL PHONE: (_______) ____________________ STUDENT’S EMAIL: ________________________________
DATE OF BIRTH: ______/_______/_______ AGE: _________ SOCIAL SECURITY# ___________-__________-__________
Month Day Year
SEX: Male Female U.S. CITIZEN? Yes No
NOTE: IF NO, WILL NEED COPY OF RESIDENT ALIEN (GREEN) CARD
ETHNICITY: (check one) Hispanic or Latino (Cuban, Mexican, Puerto Rican, South or Central American) Not Hispanic/Latino
RACE: (check all that apply) American Indian/Alaskan Native Black or African American Hispanic or Latino
White Asian Native Hawaiian or Pacific Islander Other
_____________________
CURRENT GRADE: 9
th
10
th
11
th
12
th
CURRENT SCHOOL: ________________________________ What grades do you usually get? _____________________
What was your last semester grade point average (GPA)? (Check one) Please provide copy of HS transcript
(A) 4.0 and above (B) 3.0 -3.9 (C) 2.0 -2.9 (D) 1.0 -1. (F) below 0.9
Are you currently a participant in Talent Search or Upward Bound? Yes No
HOUSEHOLD INFORMATION
Family size: _____________________
(total number currently living in your household and supported by parent/guardian)
With whom does the student live?
Mother only Father only Mother and Father Parent/Step-parent
Legal Guardian: _________________________________ Other (specify): ____________________________
Parent/Guardian 1 Name: ___________________________________________________________________________
Occupation: __________________________________________ Work Phone: _________________________________
Parent/Guardian 2 Name: ____________________________________________________________________________
Occupation: __________________________________________ Work Phone: _________________________________
Has either parent in your current household received
a 4-year degree from a college or university? Yes No
FAMILY INCOME INFORMATION
For OCCC to determine eligibility for Upward Bound participation, federal regulations require documentation on the
applicant’s family size (# of exemptions) and taxable income from the last calendar year. Please complete ONE
on the
appropriate sections below:
SECTION 1 Please note that the Annual Taxable Income is located on line 43 of Form 1040, on line 27 of Form 1040A
and on line 6 of Form 1040EZ. The Taxable income is usually lower than the Adjustable Gross Income which is located at
the bottom of the first pages of most tax forms. (Attach a copy of tax forms)
Please call 405-682-7865 if you have any questions or need assistance locating this information.
What is your household’s Annual Taxable Income for the previous year? ____________________________
SECTION 2 FOR FAMILES WHO WERE NOT REQUIRED TO FILE AN IRS 1040 OR 1040A FORM
Family Size: _______________ Total earnings (GROSS INCOME) for the previous tax year: $________________
Sources of Income: ____________________________________________________________
If any of the sources of income listed below apply to you, please complete the appropriate section:
Social Security Benefits $____________________________
Welfare Benefits $_________________________________
TANF Benefits $___________________________________
Other Please List: ________________________________$____________________
SECTION 3 (Check if applicable) APPLICANT IS A FOSTER CHILD APPLICANT IS UNDER GUARDIANSHIP
(Agency: ________________________________________________________) Documentation attached
I hereby certify that the information and attached documents provided to support this application are true and correct,
and that deliberate misrepresentation of the information may subject me to prosecution under applicable state and
federal laws.
Additionally, I understand that the information given herein and supporting documents are for the receipt of Federal
assistance. Officials handling this application may verify the provided information using either computer matching
programs, or by other means, with other Federal or State Agencies. [Note: The information you provide may be disclosed
to third parties for the purpose of verifying eligibility requirements, and in an effort to prevent fraud, waste, and abuse in
providing federal assistance.]
___________________________________________________________ _______________________________
Parent or Legal Guardian’s Signature Date
___________________________________________________________ _______________________________
Student Signature Date
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