Upward Bound California State University Monterey Bay Eligibility Application Federally Funded by the U.S. Department of Education In order to determine your eligibility to participate in our Upward Bound program, please answer all sections completely. Please use a blue or black pen and print clearly. If you have questions, please call the Upward Bound Office at: (831) 582-4600 Incomplete forms will not be accepted!

Student Section: Student's Name:

Social Security Number:

Street Address:

City:

Student Cell: Sex:

Male

Home Phone: Female

U.S. Citizen?

YES

Grade Level:

8th

High School:

Email Address:

Place of Birth: NO

Zip:

Birth date:

/

/

If Not Citizen, please provide USCIS / A Number:

9th

10th

11th

North Monterey County

Student ID:

Pajaro Valley

Soledad

Watsonville

Where did you find out about the Upward Bound Program? Classroom presentation

Referral – Name:

Are you currently participating in one of these pre-college programs? AVID Talent Search EAOP Migrant Program *Please provide a copy of your current transcripts*

Other:

Overall G.P.A.:

Parent/Guardian Section: Mother/Guardian

Father/Guardian

Name: Occupation: Highest grade level of education completed (please CIRCLE one): High School

0 9 10 11 12

0 9 10 11 12

College (4-year)

1 2

1 2

3

4

5+

College degree completed by either parent? If YES, which one? Mother:

BA/BS

Yes

3

4

5+

No Country

MA/MS

Ph.D

Father:

BA/BS

MA/MS

Family Size and Income Information: (To be completed by the parent/guardian) *Please provide a copy of your 1040, 1040A or 1040EZ Federal Income Tax Form *Por favor proporcione una copia de sus Impuestos Federales 1040, 1040A o 1040EZ Number of household dependents/Número de dependientes: Indicate type of income/Indicar el tipo de ingresos: Salary/Salario Social Security/Seguridad Social Welfare (TANF/AFDC) Retirement/Jubilación Unemployment/Subsidio de desempleo Other/Otro (explain/explique): Revised 1/22/19

Ph.D

RELEASE OF SCHOOL RECORDS I authorize the Upward Bound Program to obtain any or all copies of my academic records, progress reports, end of six weeks report cards, complete and official high school transcripts, state mandated testing scores and records. Autorizo el Programa Upward Bound a obtener y/o recibir copias del expediente academico, reportes de calificaciones, puntuaciones de examenes de mi hijo/a necesarios para completar el proceso de admisión al programa. Parent and student signatures/Firmas: Parent’s signature/Firma del padre/madre: ______________________________________Date/Fecha: _____________ Student signature/Firma del estudiante: _________________________________________Date/Fecha: _____________ Certification:

We certify that the responses on this form are accurate and complete to the best of our knowledge and that any misrepresentation may be cause for denial or cancellation of admission. We understand that we may be requested to provide income documentation and proof of citizenship if admitted into the Upward Bound Program. Certifico que la información declarada en esta aplicación es correcta y completa a lo mejor de mi conocimiento. Cualquier información falsa puede ser la causa de la cancelación de esta aplicación o suspensión inmediata del programa. Entendemos que se me puede solicitar a proveer documentación adicional sobre impuestos o ciudadanía si es admitido al programa. Parent’s signature/Firma del padre/madre: ______________________________________Date/Fecha: _____________ Student signature/Firma del estudiante: _________________________________________Date/Fecha: _____________

***REMEMBER*** Provide a copy of the following documents Incomplete forms will not be accepted! *Please provide a copy of your current transcripts *Please provide a copy of your Social Security Card *Por favor proporcione una copia de su tarjeta de segurida social *Please provide a copy of your parent’s 1040, 1040A or 1040EZ Federal Income Tax Form *Por favor proporcione una copia de sus Impuestos Federales 1040, 1040A o 1040EZ de sus padres RETURN THIS COMPLETED FORM TO A TRIO UPWARD BOUND STAFF MEMBER OR YOUR HIGH SCHOOL GUIDANCE COUNSELOR. - OR MAIL TO: TRiO Upward Bound Program CSU Monterey Bay 100 Campus Center Bld 47 Seaside, CA 93955

FOR OFFICE USE: Received Eligibility Application Date: _____/______/____ First Generation Low Income Upward Bound Eligible? Yes No

_

U.S. Citizen/Permanent Resident Staff Signatures: __________________________________Date: _____________