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Upward Bound is a free program that provides (Feather River Community College District)

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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.
STUDENT INFORMATION
Legal Name: ____________________________________________________ Social Security #: ______-______-________
Last First Middle (Mandatory per Federal Guidelines)
Home Address: _____________________________________________________________________________________
(Apt. #) City State Zip
Mailing Address:
City State Zip
Home Phone #:___________________________________ Student Cell #: ______________________________________
Student Email Address: _______________________________________________________________________________
Date of Birth: ______ / ______ / _______ Age: _________ Sex: M F
School Attending: _______________________________ City: ________________________Grade Level: _____________
Race/Ethnic Background:
Do you identify as Hispanic/Latino Yes No
What is your race/ethnicity (please check all that apply):
American Indian/Native American Asian Black/African American
White/Caucasian Native Hawaiian/Pacific Islander
Primary Residence:
Parent(s) Foster Home Legal Guardian (relationship) _______________ Someone other than Legal Guardian
Are you an emancipated minor (independent from parents)? No Yes If yes, please attach documentation
What is the primary language used in your home?
Do you have a documented disability? Yes No If yes, please attach documentation
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. I agree to monitor the progress of my child. I agree to call the office at 530-283-0202 ext.266, if I 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 in the
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.
Student’s Signature ___________________________________________________________________Date_________________
Parent/Guardian’s Signature___________________________________________________________Date__________________
Feather River College
570 Golden Eagle Ave.
Quincy CA, 95971
(530) 283-0202 ext. 266
FAX (530) 283-3890
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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 Name: _____________________________________email address: ___________________________________
Address: _________________________________________________________________________________________
Occupation: _____________________________________ Employer:_________________________________________
Cell#: ___________________________ Home#:__________________________ Work#:__________________________
Highest Grade Completed by Natural or Adoptive Mother:
Unknown Elementary High School College Received 4-year degree (bachelor’s degree)
Father’s Name: _____________________________________ email address: ____________________________________
Address: ___________________________________________________________________________________________
Occupation: ____________________________________ Employer: __________________________________________
Cell#: ___________________________ Home#:__________________________ Work#:__________________________
Highest Grade Completed by Natural or Adoptive Father:
Unknown Elementary High School College Received 4-year degree (bachelor’s degree)
Guardian/Step--Parent Name: ____________________________________ email address: _________________________
Address: ___________________________________________________________________________________________
Occupation: ______________________________________ Employer: _________________________________________
Home# ________________________ Work#:____________________________Cell#:_____________________________
With whom does applicant live? Mother Father Both Mother & Father Other (specify):__________________
Who financially supports the applicant? Mother Father Both Mother & Father Other (specify):_____________
Is the applicant a (select one): U.S. Citizen or Eligible Non-citizen #: _____________________________________
Country of Birth: _________________________________
What was your family’s Taxable Income for 2019? Your TAXABLE income is less than your adjusted gross income and can
be found on line 10 of your federal tax return. Please attach a SIGNED COPY of your most recent federal tax return.
Taxable Income for 2019: ____________________________ I had no taxable income for 2019
Number of persons supported by this income during 2019: (including parent(s) and /or guardian(s)
I certify that all of the information (provided by me or my child) contained in this application is true and correct.
►__________________________________________________ ____________________________________________
Parent/Guardian Signature Date
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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 Date
►_____________________________________________________ ________/_______/_______
Student’s Signature Date
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 Date
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 Date
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 Date
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 I 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:
Allergies_______________________________________Medications_________________________________________
Insurance Name & Number____________________________________________________________________________
►_____________________________________________________ ________/_______/_______
Parent’s Signature Date
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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.
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
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Completed 4 September 2020

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