UB Application - Welcome To Rio Hondo Community College

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UB Application - Welcome To Rio Hondo Community College Powered By Docstoc
					                                     Rio Hondo College District
                                      Upward Bound Program


                                            Student Application Form
                                                                                            Date:

TO THE APPLICANT: This information helps determine your eligibility for the Upward Bound
Program. All information submitted will remain confidential.

                                              STUDENT INFORMATION
PLEASE PRINT CLEARLY.
 L Name:                                         F Name:                                            MI:

 SSN#:              /         /                  Date of Birth:       /         /                   Gender:       M / F

 Address:                                        City:                                    State:           Zip:

 Phone: (       )         -               Cell/Work: (      )     -            Email:

 School Attending:                                                        Grade Level:              GPA:


                                                         ELIGIBILITY

1). Citizenship:
Place of Birth:
U.S. Citizen?           Yes       No OR       Permanent Resident?           Yes. If yes, card # :



2). First Generation:
Father’s Educational Level: Elementary           Jr. High       High School         Some College          B.A. Completed
Mother’s Educational Level: Elementary           Jr. High       High School         Some College          B.A. Completed


3). Low Income:
Total number of family members
If your parents file their Income Tax, answer the following:
      1. Report Total Income here               $___________
      2. Report Taxable Income here             $___________

If your parents DO NOT file their Income Tax, answer the following:
      1. Report Source of Income here           ___________ (example: Social Security, Public Assistance, etc)
      2. Report Total Earnings here           $___________


4). Other Academic Programs:
Are you presently a participant of any of the following student academic development programs?
(Please Check)   Talent Search      MESA      Cal SOAP     UC Partnership/EAOP    AVID
                  Other Upward Bound, If yes, please specify from which college:


Please complete the questions on the back of this form
                                                                                                      Revised on 2/01/06
                                                                                                                     FM
                                       Rio Hondo College District
                                        Upward Bound Program


                                                       DEMOGRAPHICS

Ethnicity:
   American Indian or Alaskan Native (1)                     White (5)
   Asian (2)                                                 Native Hawaiian or Pacific Islander (6)
   Black or African American (3)                             More than one race (7)
   Hispanic or Latino (4)                                    Tribal Affiliation:

Disability:
Do you have a physical Disability?               Yes       No Type:

                                                FAMILY INFORMATION

Are you an Orphan or Ward of the Court? Yes                         No

Father/Legal Guardian Name
Currently Employed? Yes    No

Mother/Legal Guardian Name
Currently Employed? Yes    No

How many brothers/sisters do you have?
How many brothers/sisters attended or are attending college?
Language predominately spoken at home by parents:



                                                       CERTIFICATION
I certify that the information I have given on this application is true. I wish it to be used to determine my eligibility to
participate in the RHC Upward Bound Program. If I am accepted as a participant, I agree to abide by the rules and regulations
of the program. I also agree to release my high school and academic records to the Rio Hondo College Upward Bound
Program.

Student Signature:                                                                              Date:


I certify that the information I have given on this application is true. If my son/daughter is accepted as a participant, I agree
to participate in meetings, orientation sessions and workshops organized by the Program, as required for the purposes of
improving my child’s chances of educational and personal success. Also, I agree to allow my child’s high school and academic
records released to the Rio Hondo College Upward Bound Program.



Mother/Guardian Signature:                                                                      Date:

Father/Guardian Signature:                                                                      Date:


                      The Rio Hondo College Upward Bound Program does not discriminate against any applicant on
                      the basis of race, sex, disability, national origin, religion or political affiliation.



                      “The contents of this application were developed under a grant from the Department of
                      Education. However, those contents do not necessarily represent the policy of the Department
                      of Education, and should not assume endorsement by the Federal Government.”
                    Upward Bound Application Instructions


Take time to explain the program to your parents, teacher and counselor and have them give us a
call if they need more information. Only a counselor or teacher can recommend you to the program
by completing the counselor/teacher recommendation form.

Please make certain that all information is accurate and clearly stated. Any important information
missing or withheld will be considered incomplete and will not be processed. Remember this
program is on a first come first serve basis.

Make sure you turn in ALL of the following application documents:
     Student Application Form
     Application Essay Form
     Parent Permission and Medical Information Form
     Counselor/Teacher Recommendation Form
     You must also submit a copy of your most recent high school transcript



Applications are due by:
Return applications to:



The Upward Bound Program is located at:                          Upward Bound Staff:
Rio Hondo College (Room T103)                                    Trio Director:       Dr. Zolita Fisher
3600 Workman Mill Rd.                                            Educational Advisor: Norma Garcia
Whittier, CA 90601                                               Tutors:              Eloise Valdivia
(562) 692-0921 ext 3201                                                               Mayra Serrano
                                                                                     Ignacio Andrade




After we have received your completed application, we will contact you to schedule an Orientation
with you and your parents. At the Orientation you will be asked to submit a COPY of the following
documents (failure to submit these documents will disqualify you from the Upward Bound Program):
        Copy of Birth Certificate (and Resident Alien Card, if born outside the U.S.)
        Copy of Social Security Card
        Proof of Income:
         If parents filed taxes, then you must turn in the first TWO PAGES of the federal tax return
         with your parent’s signature.
                            Or
         If your parents do not file taxes, then you must turn in PROOF OF INCOME.

   *These documents are a requirement of the Upward Bound Program.
    All information will be kept in a file and remain CONFIDENTIAL.

				
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