Fillable Phase I (Student) Complete and sign MTC Upward (Midlands Technical College)

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Phase I (Student) Complete and sign MTC Upward (Midlands Technical College)

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Phase I (Student)
Complete and sign MTC Upward Bound Application
Submit your completed application to your Guidance Counselor
Phase II (Guidance Counselor)
Complete Guidance Counselor Recommendation form
Submit Official Middle School and/or High School Transcript(s) –Including student’s test results from State Standardized Test
and SAT/ACT scores if applicable
Guidance Counselor: Please mail or fax the student’s completed application to the Upward Bound Program
Phase III (Student)
Parent/Student Interview – Please note that after you submit your MTC Upward Bound Application Packet, you and your
parent(s)/guardian(s) will be contacted by the Upward Bound Administrative Specialist to schedule an on-campus interview with
the Upward Bound Staff. During the interview, the staff will discuss with you and your family your educational and personal
goals.
Income verification – All students must submit a signed copy of their biological or adoptive parent(s)’ most recent Federal
Income Tax Return during the on-campus interview. If you are in foster care, a homeless youth, at risk of being homeless,
unaccompanied youth, or you have special circumstances, please notify the Upward Bound Administrative Specialist at
803.822.3384. If you are unable to locate your most recent Federal Income Tax Return, please contact your tax preparer or the
IRS for a Tax Transcript.
Complete Information Release Form and Student Profile Form
MTC Upward Bound Program• PO Box 2408 • Columbia, SC 29202 • MIDLANDSTECH.EDU/ub • 803.822.3384
Midlands Technical College does not discriminate in admissions, educational programs or employment on the basis of race, sex, national origin or ethnic group, color, age, religion, disability,
genetic information, gender, military service, or pregnancy. In compliance with all federal and state laws, including Title V I and Title VII of the Civil Rights Act of 1964 and Title IX of the
Education Amendments of 1972, Sections 503 and 504 of the Rehabilitation Act of 1973, and the Americans with Disabilities Act of 1992 as well as the ADA Amendments of 2008 (ADAA), and
the Genetic Information Nondiscrimination Act of 2008 (GINA), Midlands Technical College offers access and equal opportunity in its admissions policies, academic programs and services,
and employment of disabled individuals in that no otherwise qualified person will be denied these provisions on the basis of a disability. Mr. Ian A. MacLean has been designated to
coordinate compliance with the nondiscrimination requirements contained in Section 35.107 of the Department of Justice regulations, Sections 503 and 504 of the Rehabilitation Act of
1973, Title VI and Title VII and Title IX regulations. Information concerning the provisions of the Americans with Disabilities Act and the rights and privileges thereunder are available from Mr.
Ian A. MacLean in his position as Interim Director of Internal Auditing and Risk Management and the Chief Compliance Officer for Affirmative Action, Equal Opportunity, Sexual Harassment
and Disability Action. He can be reached at Midlands Technical College, P.O. Box 2408, Columbia, SC 29202, 803.822.3204.
Although the UB staff is employed by Midlands Technical College, they do not recruit participants for the college.
As a UB participant, students can participate and receive assistance in applying to any vocational training program, college, and/or university.
Section 1. Student Information
Today’s Date: _________________________ Social Security Number _____________________________________________
First Name ________________________________ Last Name _________________________________ Middle Initial __________
Mailing Address ______________________________________________ Apt. # __________ Email _________________________
City ________________________________________________________________ State __________ Zip Code _______________
Phone Number (H) ____________________ (C) ____________________ Date of Birth _____/_____/__________ Age ________
Gender: Male Female
Race: (Check one) Black/African-American American-Indian/Alaska Native Asian White/Caucasian
Hispanic/Latino Native-Hawaiian/Pacific Islander Multicultural Other/Unknown
Are you a U.S. citizen? Yes No
If no, are you an eligible non-citizen? Yes No Alien Registration Number A_____________________________________
Is English your first/primary language? Yes No
Are you currently a participant in another TRiO or federal program such as Talent Search, Upward Bound, and/or Gear-up?
Yes No If yes, in which program are you a participant? ________________________________________________
Section 2. Secondary School Information
I am currently enrolled in middle school. Current Grade Level: ______________________
(Please list the complete name of your middle school)________________________________________________
I am currently enrolled in high school. Current Grade Level:__________ Expected Date of Graduation:______/______/________
(Please list the complete name of your high school)________________________________________________
Please list the name of the guidance counselor and the teacher who will provide a reference for you:
Guidance Counselor’s Name: _____________________________ Email Address: ____________________________________
Section 3. Needs Assessment
What category of service would you like to receive from the MTC Upward Program? (Check all that apply)
ACT/SAT Preparation Career Counseling College Admissions Counseling
College Tours Cultural Event Enrichment Educational Referral Services
Educational Counseling FAFSA Assistance Foster Youth and Homeless Educational Assistance
Financial Aid Counseling Financial Literacy Interest/Aptitude Testing
Scholarship Information Student Loan Counseling Tutoring
Other ___________________________________________________
What do you plan to do after you graduate from high school?
Attend a two-year college Attend a four-year college Attend a vocational or trade school
Enlist in military Get a job Other: _________________________
Section 4. Dependency Status
Are you any of the following?
A dependent or ward of the court
An emancipated minor
In foster care or was previously in foster care
Both parents are deceased
Currently in legal guardianship
Homeless or at risk of being homeless
I have special circumstances and I am unable to provide my parental information at this time
If you answered yes to any of the questions in Section 4 above, you are not required to complete Sections 5-6 of this application.
Sections 5 through 6 To Be Completed by Parent(s) or Legal Guardian
Please answer the following questions on behalf of your child or dependent listed on Page 1 of this application.
The U.S. Department of Education requires the MTC UB Program to have income information on file for a participant’s parent(s) in order to
determine first-generation and low-income eligibility.
Section 5. Parent/Guardian Information
Parent/Guardian 1
First Name ________________________________ Last Name _________________________________ Middle Initial _________
Phone Number (H) ______________________ (C) ______________________ Email:_____________________________________
Highest level of school biological or adopted Parent 1 completed? (Please note, if you are the student’s guardian, please answer
this question on the biological Parent 1.)
Middle School/Jr. High High School 2-year college
4-year college or beyond Other/Unknown
Parent/Guardian 2
First Name ________________________________ Last Name _________________________________ Middle Initial _________
Phone Number (H) ______________________ (C) ______________________ Email:_____________________________________
Highest level of school biological or adopted Parent 2 completed? (Please note, if you are the student’s guardian, please answer
this question on the biological Parent 2.)
Middle School/Jr. High High School 2-year college
4-year college or beyond Other/Unknown
Section 6. Student’s Income and Household Information
1. Did you [the student’s biological or adoptive parent(s)] complete an income tax return? Yes No
If yes, please attach a completed and signed copy of the most recent Federal Tax Return when the completed application is submitted.
2. Household size (number of family members)? _________
To determine the household size, include:
The student applying for admission into the MTC Upward Bound Program;
Yourself [the parent(s)];
The number of other children who will receive more than half of their support
from you [the parent(s)] this school year; and
The number of people who are not your children but who live with you and receive more than half of their support from you, and will
continue to receive more than half of their support from you this school year.
3. What is parent(s)’ marital status as of today? Single Married Divorced Separated Widowed
4. Who does the student listed reside with?
Mother Father Mother and Father Mother and Stepfather Father and Stepmother
Foster Parent Guardian Other: ________________________________________________
5. Did the student or anyone in the student’s household receive benefits from any of the following programs? (Check all that apply.)
Free or reduced-priced lunch Temporary Assistance for Needy Families (TANF) Food stamps/SNAP
None Special Supplemental Nutrition for Women, Infants and Children (WIC)
Section 7. Certifications
Please read the following statements and check the boxes verifying that you have read and agree.
We certify that the information provided on this application is true and correct to the best of our knowledge.
We understand that the information provided on this application will be held in strict confidence by the UB staff.
We understand that if the student needs accommodation for a disability to participate in UB or in any of its scheduled
activities, we must contact the UB Program at 803.822.3384 at least 30 working days prior to the activity.
Student’s Signature: _______________________________________________________ Date: ________________________
Parent’s Signature: ________________________________________________________ Date: ________________________
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To the high school guidance counselor: Please fill out this form completely.
Please submit:
⎕ Completed Guidance Counselor Recommendation Form;
⎕ Student’s middle/high school transcript with standardized test scores and SAT-I/ACT scores; and
⎕ Please mail form with student application to Midlands Technical College Upward Bound, PO Box 2408, Columbia, SC 29202;
email: ub@midlandstech.edu
; Fax: 803.822.3414
Thank you for your assistance.
Section 1. (This section to be completed by the student.)
First Name ____________________________ Last Name ____________________________ Middle Initial ________________
After you have completed Section 1, give this form to your guidance counselor.
Section 2.
Counselors, please complete this form and send to the UB Program via email at ub@midlandstech.edu or fax to 803.822.3414.
The above named student has applied for admission to the MTC Upward Bound (UB) Program. The UB Program is designed to provide support services to high
school students (grades 9-12) in order to prepare them to graduate from high school and enroll and graduate from college. Upward Bound is funded by the US
Department of Education and serves students in designated high schools in Lexington and Fairfield counties.
Secondary School: ______________________________________ Counselor’s Name: ___________________________________
Counselor’s Phone Number: ______________________________ Counselor’s Email: ____________________________________
If the student is currently in 8
th
grade, what high school will the student attend the following academic year?
_________________________________________
1. The student’s GPA is ______ on a 4.0 scale Class Rank is ________ in a class of __________
2. I have known the applicant for ______ months or ______ years
3. How would you categorize the rigor of the student’s academic program? If currently in middle school, please evaluate the
courses the student will enroll in as a ninth grade student:
AP and IB Honors College Prep Other__________________________________________
4. Upon graduation, will the student have completed the CHE high school course prerequisites for applicants to apply to a South
Carolina public colleges and universities? Yes No N/A
5. Does the student have an IEP? Yes No
6. Has the student ever been suspended or expelled? Yes No
7. School Attendance: Regular Irregular No. of days missed _______________________
8. Is the student currently participating in APEX and/or credit recovery? Yes No
If yes, what subject(s): ______________________________________________________________________________________
9. Would you recommend this student to participate in the Upward Bound Program?
Highly Recommend Recommend Recommend with Reservations Do Not Recommend
South Carolina Assessments:
Exemplary
Met
Not Met
Writing
English Language Arts
Math
Science
Social Studies
Counselor’s Signature: ___________________________________________________ Date: ______________________________
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Completed 4 February 2021

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