Instructions

The following information is required and will be treated in a confidential manner.  The student applicant and his/her parent/guardian must complete all items on the application and return the requested documents before the student will be considered for acceptance into the TRIO Upward Bound program.

There are four (4) sections to this application.

SECTION 1: Student Information

Completed by the STUDENT
Student signature is required

 

SECTION 2: Head of Household Statement

Completed by HEAD OF HOUSEHOLD (PARENT/GUARDIAN).
Parent/guardian signatures are required.

 

SECTION 3: Release and Reccomendation Forms

Agreements and Release forms.
ACADEMIC RELEASE FORM must be downloaded, printed and delivered to Principal or Registrars of school to be completed.

Student signatures are required.

 

SECTION 4: Required Documents

  1. Student’s most recent transcript or report card (may be obtained from guidance counselor at school).
  2. Recommendation form from guidance counselor or teacher.
  3. Copy of student’s Social Security OR Permanent Resident Registration Card.
  4. Income verification (i.e. tax return, welfare statement, SSI, etc.).

We will not advance incomplete applications to the interview stage.

 

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Section 1 of 2
Student Information
___________________________

Check here if you do NOT want to receive texts:
Gender Identity:
Ethnic Background
Citizenship
Are you enrolled in TRIO Talent Search Program at your high school?
Do you feel that your grades are a true reflection of your ability?
Please explain your answer below


STUDENT'S INTEREST IN UPWARD BOUND
By typing YOUR NAME you are verifying this as your signature.
By typing DATE you are verifying this as your signature date.


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Section 2 of 4
Head of Household Statement
___________________________

This section must be filled out by the Parent(s)/Guardian(s)


Student lives with:
First Middle initial Last
First Middle initial Last
First Middle initial Last
First Middle initial Last
First and Last name of contact
City, State, Zip code

HEAD OF HOUSEHOLD

Please list yourself and all your DEPENDENTS below. Dependents are those people who are supported by your income and include the student who is applying.



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Student 
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______________________________________
Dependent #1
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______________________________________
Dependent #2
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______________________________________
Dependent #3
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______________________________________
Dependent #4
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______________________________________
Dependent #5
↓    ↓    ↓    ↓    ↓   ↓    ↓    ↓    ↓    ↓   ↓    ↓    ↓


Did the family file a Federal Income Tax Return last year?
Parent income/support sources
My student is eligible for Free Lunch

This application cannot be processed unless accompanied by a copy of your most recent Federal Tax Form 1040/1040A/1040EZ.  For those who are married but file separately, both individuals’ tax forms must be copied.

Official statement of annual benefits must be provided if family receives income from any of the above sources.

 


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Parent/Guardian Certification and Release
↓    ↓    ↓    ↓    ↓   ↓    ↓    ↓    ↓    ↓   ↓    ↓    ↓

  • I certify that the information on this application is correct.

  • I give consent to North Shore Community College’s TRIO Upward Bound Program (UB) to secure and review all information, including academic transcripts, needed to provide educational services to the student named above while he/she is enrolled in the UB Program.

  • I also give permission to the UB staff to access the student’s educational enrollment history information through the National Student Clearinghouse for the purpose of data reporting.

  • As parent or guardian signing this form, I give permission for my child to participate in all program sponsored activities at North Shore Community College.

  • I also give permission for the use of my child’s name and/or photograph for editorial, promotion, recruitment, or educational purposes.


By typing NAME you are verifying this as your signature.
By typing DATE you are verifying this as your signature.

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Section 3 of 3
Release and Recommendations Forms
___________________________
Academic Release Form


To the Principal or Registrar’s Office:

I (student) hereby authorize you to release from your records to North Shore Community College's TRIO Upward Bound Program, the data requested below concerning the following student. The release will be in effect through his/her completion of high school and for six years following his/her graduation to allow for annual tracking of UB participant’s education as is required by Federal Department of Education regulations to evaluate the UB Program. I understand that this information will be held in compliance with FERPA and other applicable state laws and will only be accessible to appropriate program staff and Department of Education personnel.

This link will bring you to the required form to download, print, complete and bring to the Principal or Registrar of your school.




MEDIA REQUEST
Request for the Upward Bound program and affiliates to use pictures, videotapes or audio recordings of the above-named student for all program-related purposes, including for publication in newspapers and other media.

STUDENT CONSENT AND PARTICIPATION AGREEMENT

I (student) understand that by participating in the Upward Bound program I will be participating in a federally funded TRIO program designed to help me graduate high school and continue on to post-secondary education. Accordingly, I understand that I am subject to the program policies and procedures and if accepted into the program, I agree to the following:

  1. To strive to attain personal, academic, and career goals that I set for myself. 
  2. To treat myself, other students, and staff with respect, and be a positive representative of the program.
  3. To attend school every day.
  4. To periodically/as scheduled meet with my TRIO advisor
  5. To attend relevant workshops and to fully participate in the program.
  6. To demonstrate model behavior in and out of school, including while on UB field trips.
  7. To share academic information with UB staff in order to assist in planning and tracking.
  8. To have fun and do my best!

I have read the above rules and promise to uphold them and to be a good representative of my school and the UB program. I understand that while participating in UB activities I am held to the UB program policies and the policies outlined in my school’s student handbook and that any serious breach of behavior may result in dismissal from the program.


Additionally, I understand that to facilitate successful participation in the program and for data reporting, UB staff need access to my academic records throughout my participation in the program and my post-secondary enrollment and graduation information after high school. I understand this consent will remain in effect until its written revocation is received by the UB program at NSCC, 1 Ferncroft Road, Danvers, MA 01923.

 

 

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