Fillable LBCC UPWARD BOUND PROGRAM 2019-2020 STUDENT ELIGIBILITY FORM (Long Beach City College)

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LBCC UPWARD BOUND PROGRAM 2019-2020 STUDENT ELIGIBILITY FORM (Long Beach City College)

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LBCC UPWARD BOUND PROGRAM
2019-2020 STUDENT ELIGIBILITY FORM
The Long Beach City College Upward Bound Program is a federally funded initiative that
encourages eligible students to complete high school successfully and continue on to post-
secondary education. Participants must meet the eligibility criteria of being low-income and/or
first generation. Completing this eligibility form does NOT mean you have been accepted into
the program. However, we review all eligibility forms and schedule an information session and
interview with students who are eligible. Please return completed form to the UB Program
Specialist, Ms. Morales, or email a copy to upwardbound@lbcc.edu.
STUDENT INFORMATION
Student Name Student ID Number
High School Attending Grade Birth Date
Birthplace ______________________________ Ethnicity_____________________________
Address
Street Apt. City Zip code
Student Cell __________________________Parent/Guardian Cell ________________________
Student Email
Parent Email ______________________ ________________
High School Counselor Name
1. Are you currently enrolled in Talent Search, EAOP, or Gear Up? Yes No
2. Do you wish to attend college after you graduate from high school? Yes No
3. Did you pass the ELA caaspp, standardized testing? Yes No
Math caaspp, standardized testing? Yes No
4. What is your current overall GPA? _________ (please attach current progress report or
unofficial transcript)
5. Are you a U. S. citizen or resident? Yes No
6. How did you hear about Upward Bound?
7. Do you have a family member in the program? ___ Yes___ No Who? ______________
FAMILY INFORMATION
8. Parent/ Guardian Name: _______________________ Occupation: __________________
9. Parent/ Guardian Name: _______________________ Occupation: __________________
10. Education background (Please mark the appropriate box and identify the birth parent who has the
highest level of education
)
Highest education level or degree your birth parent(s) completed:
( ) Unknown ( ) Middle school ( ) High School ( ) A.A./ A.S. ( ) B.A./ B.S. ( ) Other
Please complete back of form
For UB office use only
Income: _____________
Education: ___________
FINANCIAL INFORMATION
11. Does your parent/guardian receive CalFresh, CalWORKs, Kin-GAP or SSI?
Yes No
12. How many people are there in your "household"? ("household" is defined as the
total number of persons who are related to you by blood, marriage or adoption and are dependent on the
head of the household for support. A stepparent or stepchild is considered related by marriage.)
13. Is your parent/guardian required to file an income tax form? Yes No
14. What was your parent/guardian's taxable income? (This information can be found on any
of the forms listed below) $_________________________
IRS FORM 1040----LINE 37
IRS FORM 1040A--LINE 22
IRS FORM 1040EZ--LINE 6
I certify that the information I have given on this application is true. I agree for the release of my/my
c
hild’s high school and postsecondary academic records to the LBCC Upward Bound Program.
Student name Student signature Date
Parent/guardian name Parent/guardian signature Date
The
LBCC Upward Bound Program complies with Federal civil rights law and does not discriminate on the basis of
race, color, national origin, age, disability, or sex. Funded by the U.S. Department of Education.
Please return this form along with your most recent transcript or progress report to your school
career center or deliver it to the LBCC Upward Bound office at Pacific Coast Campus 1305 E.
Pacific Coast Hwy. Long Beach, CA 90806. Our offices are located in AA109.
If you have questions, please call Wendy Porter-Coste, Upward Bound Program Director at
(562)938-3176 or Liza Morales, Upward Bound Program Specialist at (323)400-7643 cell. Thank
you for your interest and we will contact you for an interview.
ALL INFORMATION PROVIDED WILL BE KEPT CONFIDENTIAL
upwardbound@lbcc.edu (562)938-3176
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LBCC UPWARD BOUND PROGRAM 2019-2020 STUDENT ELIGIBILITY FORM (Long Beach City College)

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Completed 25 July 2020

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