Application
For Admission
Mott Community College
Upward Bound Program
1401 East Court Street
Flint, MI 48503
810-762-5117
PERSONAL INFORMATION
Please Print Clearly
First Name: ____________________________
Last Name: ________________________________
Address: _______________________________
City: _____________________________________
Zip Code: ______________________________
U.S. Citizen? Yes___________ No ____________
Birth date:_________/_________/____________ Gender: Male ____________ Female ___________
Month
Day
Year
Phone: ________________________
Alternate Phone: ___________________________
Racial/Ethnic Group: (Select all that apply)
1. Hispanic
5. White
2.American Indian/Alaskan Native
6.Hawai or Other Pacific Islander
3.Asian
Current School: _________________________________
4.African-American
Grade:___________________
Counselor: ______________________________
Are you involved any other programs? ______ Talent Search ______ Gear UP ______
BSIP _____COE _____
Other: _____________________________________________
PARENTAL/GUARDIAN INFORMATION
With whom does the student live?
Both parents/adoptive parents
Father/adoptive father only
Legal Guardian(s) (please specify) ____________________
Mother/adoptive mother
Mother/Guardian Name: ____________________________________________________________
Address: __________________________
Occupation: ____________________________
Highest of Education Level Reached:
Elementary (K-8)
High School (9-12)
Bachelor’s Degree
Graduate Degree
Home Phone: _____________________________
Work Phone: _____________________________
Some College
Associate Degree
Father/Guardian Name: ____________________________________________________________
Address: __________________________
Occupation: ____________________________
Highest of Education Level Reached:
Elementary (K-8)
High School (9-12)
Bachelor’s Degree
Graduate Degree
Home Phone: ____________________________
Work Phone: ____________________________
Some College
Associate Degree
Parental Income Statement
Upward Bound is a program funded by the U.S. Department of Education. In order to insure that the MCC
Upward Bound Program follows federal income guidelines we are asking you to fill out this form and
provide income verification documentation with this application.
1.
Name of Parent/Guardian
Address of Parent/Guardian
Total number in household: How many people live in your household (include children away at college)?
Use your previous year tax return to complete the section below. Do not use the Adjusted Gross Income.
If you did not file a tax return skip to Question #3.
2.
Total taxable income: $______________________
(Please Check the Tax Form used to file your taxes.)
Form 1040
Form 1040A
Form 1040EZ
3.
If you did not file income tax, please state your source(s) of income:
FIA
Social Security:
Child Support
Pensions
Workers Compensation
Other:
Parent’s/Guardian Signature
Date
Certifying Statement
I certify that the information submitted in this application and any accompanying documentation is true to the best of my
knowledge. I understand that falsification on my part may result in disciplinary action(s), including denial of admissions. I
agree to comply with all the rules and regulations of the Mott Community College Upward Bound Program.
Signature of Applicant
Signature of Applicant’s Parent/Guardian
Date
Application check list
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Complete application form accurately, including all signatures
Have one of your teachers fill out teacher recommendation form.
Turn all your material in to your school counselor/representative for a recommendation and transcript or a copy of your
latest report card. Your counselor /school representative will deliver these to us.
After application is received, qualified applicant will receive a letter to set up an interview with applicant and applicant’s
parent/guardian.
We will process your application and notify you of our decision as soon as possible.
For further information you may call (810) 762-5117 or visit our website www.mcc.edu/upward/up_index.shtml.
Mott Community College is an equal opportunity institution and does not discriminate on basis of race, color; religion, national origin, sex,
sexual orientation, political persuasion, age, weight, handicap, or martial status in any of its education programs and activities, including
admission and employment.
For more information, contact the Human Resources Office at (810) 762-0565
General Information
General Information
•
What is Upward Bound?
o Upward Bound is a college preparation program funded by the U.S. Department of Education designed to
encourage students from low-income families and whose parents did not graduate from a four-year college to
further their education beyond high school.
•
Who is Eligible?
o The Upward Bound staff selects 9th and 10th grade students based upon the recommendations of teachers,
counselors, social service agencies and others who are acquainted with them. Upward Bound chooses those
students with academic potential who need the opportunity to demonstrate their talent. Students must be
attending or planning to attend one of the following High Schools: Southwestern, Northwestern, Beecher or
Hamady. They also must be low income and/or first generation as defined by the Department of Education.
•
How can it help me?
o Upward Bound gives the high school student a chance to find out what college life is al about and helps the
student develop those skills necessary to succeed in college. The program emphasizes reading, writing, math
and science skills along with tutoring in the student’s present curriculum. Personal, career and academic
counseling are also provided.
•
What do you do in Upward Bound?
o During the summer, Upward Bound students attend classes at Mott Community College for six weeks and
participate in a variety of academic, social and cultural activities, which include a 3-day college with dorm
experience. During their regular school year, Upward Bound students are in contact with Upward Bound staff
members including teachers, counselors and tutors through classes, home visits, counseling sessions and
tutorials.
•
Is there any cost involved?
o Upward Bound students receive a monthly stipend for participation and all programs services are cost free to
participants.
More Information can be obtained by calling Upward Bound at (810) 762-5117 or on the web at
www.mcc.edu/upward/up_index.shtml.
FOR OFFICE USE ONLY
Do not write in section below.
Application Reviewed
 Yes
Date:
Applicant’s Eligibility:
FG/LI
FG
Applicant Interviewed:
LI
Acceptance Date:
At-Risk:
SS Card (Copy):
Rising 8th  9th  10th
No
Applicant Interview Date:
Academic needs:
Grade Level to Start:
Yes
Date of First Service:
HS School Attending:
Expected graduation Cohort:
GPA:
NCES:
Counselor:
LEP:
 Yes
 No
Date of last service:
Reason for leaving code:
UB Coordinator Signature:
Date:
UB Director Signature:
Date:
TEACHER’S RECOMMENDATION
This section must be completed by school teacher
Student’s Name: ___________________________________________
Please rate the above student according to the scale on the bottom of this sheet:
Rating
Attitude toward school work
4
3
2
1
Intellectual ability
4
3
2
1
Initiative/motivation
4
3
2
1
Integrity
4
3
2
1
Influence and leadership ability
4
3
2
1
Ability to get along with others
4
3
2
1
Responsibility
4
3
2
1
Emotional stability
4
3
2
1
Attendance
4
3
2
1
Scale for Rating:
4 Exceptional
3 Good
2 Average
1 Poor
Comments: _________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Teacher’s Signature:________________
School:________________
Date:_________________