NMH Upward Bound Program Application
Student Information
This form should be filled out by the student and along with other required documents (checklist on page 2)
needs to be handed into guidance or Upward Bound by _________________________.
First Name
Last Name
Middle Name
Street Address
City
State
Zip Code
Mailing Address (if different from above)
City
State
Zip Code
Social Security #
Gender
Date of Birth
Home Phone #
Student Cell #
Email Address
Current School
Current Guidance Counselor
Middle School
Are you currently experiencing homelessness? Yes No (circle)
Race/Ethnicity: (check all that apply)
□ Hispanic or Latino/a
□ Black or African American
□ American Indian/Native Alaskan
□ Asian
□ White
□ Hawaiian or other Pacific Islander
□ Other: _____________________
Citizenship or Immigration Status: (if accepted you will be required to provide proof)
□ United States Citizen
□ Legal Permanent Resident (Green Card Holder)
□ Refugee and in process of becoming a Legal Permanent Resident
□ Other: _______________________________
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Are you in foster care? Yes No (circle)
If you circled yes:
 Students in foster care do not need to fill out or hand in the Family and Parent/Guardian Information
section of this application (students in foster care are automatically eligible for UB)
 The Release of information portion of this application and any other official documentation that UB
will need should be signed by the case worker (not foster parent).
 Please provide the name and phone number of your case worker:
Name:
Phone number:
How do you spend your time outside of school? Please give details.
□ Sports: _________________________________________________________________________
□ Religious Activities: _______________________________________________________________
□ Hobbies: ________________________________________________________________________
□ School Clubs: ____________________________________________________________________
□ Job: ____________________________________________________________________________
□ Other: __________________________________________________________________________
Essay: On a separate piece of paper answer the following questions (hand written by you, in at least two
paragraphs) and attach it to this application.
1. What is something unique about you?
2. Why do you want to be in Upward Bound and what are you willing to do for the next four years to
prepare for college?
3. Is there anything else you feel we should know about you when considering you for Upward Bound and
in order to best serve you should you be accepted?
Application Checklist: The following items need to be handed into guidance or Upward Bound by __________
in order for your application to be complete:
□
□
□
□
Student Information (pages 1 and 2 of this application) to be completed by you, the student
Essay (see above prompt and instructions)
Release of Information form (signed by you and your parent/guardian)
Family and Parent/Guardian Information and required financial documents (pages 3 and 4 of this
application) to be completed by your parent/guardian
□ Teacher Recommendation (you should ask a teacher if they will recommend you, give them the form,
and ask them to hand it into guidance or Upward Bound by ______________________)
For more information or to send in your application:
NMH Upward Bound
One Lamplighter Way, Mount Hermon, MA 01354
Phone #: 413-498-3416 / Fax #: 413-498-3415
Email: upwardbound@nmhschool.org
website: http://www.nmhschool.org/academics/upward-bound
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Family and Parent/Guardian INFORMATION
This form should be filled out by the student’s parent/guardian. The information on this form is necessary for
us to determine the student’s eligibility to participate in the Northfield Mount Hermon Upward Bound
Program. The information is protected by the Privacy Act and will remain confidential.
Student Name: _______________________________
Parent/Guardian Name (person filling out this form): _______________________________
Please answer all of the following questions/provide all of the requested information on pages 3 and 4:
1. Tell us why you feel this student needs Upward Bound:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
2. Please read and check-off each of the expectations below to confirm that you are aware of what
NMH UB will expect of you and the student.
□ Student will attend in full the 6-week Summer Academy each summer
□ Student will attend all advising meetings and required after school services
□ Student will attend UB tutoring up to twice a week if grades fall below a B
□ Parent/Guardian will work closely and communicate with UB staff to help the student be
successful in reaching their college goals
□ Parent/Guardian will attend required meetings (about 5/school year) to better prepare to help
the student get to college
3. This student is committed to going to college and is not planning to join the military. Yes No (circle)
4.



Parent/Guardian Income Information:
Total Gross Income for household (1040A line 21, 1040 line 37, or 1040EZ line 4): $_____________
Taxable Income for household (1040A line 27, 1040 line 43, or 1040EZ line 6): $_____________
Number of people in the household that depend on this income: ________
*If you file taxes, please attach a signed copy of your most recent federal tax return.
*If you are not required to file taxes, please attach a copy of one of the following proofs of income: End of
year Social Security Statement, TANF authorization card, EBT identification card, an unemployment
compensation check-stub (indicating end-of-year amount), or most recent pay stub (or pay stubs) for all
sources of income.
I certify that the information reported on this form is true.
Signature of Parent/Guardian
Date
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Student’s Family Information: (use additional piece of paper if you need more space)
Family Member
Name
Relationship
to Student
Age
Lives with
the
student?
(circle)
Legal
Guardian
(Yes or No)
Has this person
If employed,
completed a
what is their job
four year
and where do
college
they work?
degree?
(Yes or No)
Does UB have
permission to
talk to this
person about
the student?
(Yes or No)
Phone number(s) and
preferred email address
(please write clearly)
Language
this person
understands
best
Always
Sometimes
Never
Always
Sometimes
Never
Always
Sometimes
Never
Always
Sometimes
Never
Always
Sometimes
Never
Always
Sometimes
Never
Always
Sometimes
Never
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