Student Application - Long Beach City College (Page 2 of 2) in pdf

AMILY

NFORMATION

1) Father’s/Guardian’s name:

Occupation:

2) Mother’s/Guardian’s name:

Occupation:

3) Education Background (Please mark appropriate box)

Highest level or degree your father completed:

( ) unknown

( ) Middle school/Jr. High ( ) High School ( ) A.A/A.S ( ) B.A/B.S ( ) other

2-year degree

4-year degree

Highest level or degree your mother completed:

( ) unknown

( ) Middle school/Jr. High ( ) High School ( ) A.A/A.S ( ) B.A/B.S ( ) other

2-year degree

4-year degree

4) In order to establish student eligibility for the Upward Bound Program, we need to know the

household’s annual taxable income.

Total number of people in household _______________

Wages and salary: $ ___________ (before taxes)

Retirement benefits: $ _____________Social security: $ _______________

Public assistance: $ ______________ Other: $ _________________

Taxable income

for the past year was:

(See line 43 on Form 1040, Line 27 on 1040A, Line 6 on 1040EZ)

$ ___________________

Attach a copy of your tax form 1040, 1040A OR 1040EZ Income Tax Form pages 1 and 2. If not filing Income Tax

Returns and receiving state assistance, please submit proof of copy of welfare or SSI income verification forms.

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 LBCC Upward Bound Program. I realize that providing untruthful information is grounds for

disqualification from the 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 postsecondary academic records to the LBCC Upward

Bound Program.

Applicant’s Signature

Date

I certify that the information I have given on this application is true. I realize that providing untruthful

information is grounds for my son’s/daughter’s disqualification from the Program. 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 purpose of improving my child’s chances of educational and personal success. Also, I agree to allow

my child’s high school and postsecondary academic records released to the LBCC Upward Bound Program.

Father’s/Guardian’s Signature

Date

Mother’s/Guardian’s Signature

Date

The Long Beach City College Upward Bound Program does not discriminate against any applicant on the basis

of race, sex, handicap, age, national origin, religion or political affiliation.

Funded by the U.S. Department of Education.

Student Application - Long Beach City College Page 2

Related Articles

Related forms

Related Categories