TRiO Upward Bound Application

Thank you for your interest in the TRiO Upward Bound college prep program! Please complete the application as thoroughly as possible with your parent/guardian. You cannot save and restart this application. You may want to review the included items, take some time to make notes, and then return to submit your application. 

Upon receipt, UB staff will follow up to determine eligibility, forward any additional forms, solicit documentation, and schedule an orientation. If you have any questions, please call our office at 602-305-5676. We are here to help!

Student Information
First Name *
Last Name *
Middle Name
Contact 1 Address *
Contact 1 Address 2
City *
State *
Zip Code *
Student Phone Number *
Email Address *
Personal Email (HS email used for program services)
Social Security Number (if you do not have one, please enter all zeros) *
U.S. Citizen or Permanent Resident *
If you answered yes above as a permanent resident, provide A# (Alien Registration Number)
Have either parent(s) received a bachelor's degree?
Are you a ward of the court? *
Gender *
Date of Birth *
Race/Ethnicity (check all that apply):
American Indian or Alaskan Native
Asian
Black or African American
White
Native Hawaiian or Other Pacific Islander
Hispanic
Why you would benefit from SMCC’s Upward Bound Program? *
What are your personal and educational/career goals? *
Academic Information
Entry Grade Level *
Estimated Entry GPA (grade point average) *
GPA will be verified by official transcripts. 
Please check all the academic areas you would like assistance with (you may check more than one).
English Composition/Literature
Mathematics
Science
Foreign Language
English as a Second Language
Other
High School *
High School Guidance Counselor Name *
High School Guidance Counselor Email *
Do you have a disability requiring accommodations? *
Have you ever participated in any of the following TRiO programs or other college preparatory programs? *
Please select the area of career fields/interest you are most interested in. *
Parent/Guardian Information
Parent/Guardian 1 First and Last Name *
Parent/Guardian 1 Address *
Parent/Guardian 1 City *
Parent/Guardian 1 State *
Parent/Guardian 1 Zip *
Parent/Guardian 1 Phone *
Parent/Guardian 1 Employer *
Relation to Applicant *
Parent/Guardian 2 First and Last Name
Parent/Guardian 2 Address
Parent/Guardian 2 City
Parent/Guardian 2 State
Parent/Guardian 2 Zip
Parent/Guardian 2 Phone
Parent/Guardian 2 Employer
Relation to Applicant
With whom do you live with? *
Is English spoken as the primary language in your home? *
If you answered no above, please specify the primary language spoken at home.
Financial Verification
How many people are in your family including yourself? *
What is your family's taxable income? *

Taxable income is used by the U.S. Department of Education as a qualifier for this program. There are two options below to verify taxable income. Option 1- Upload your 1040. Option 2- fill out the income statement. 

 

Option 1- Families that filed a tax return will need to upload a copy of their signed and most recent 1040 federal tax form. Taxable income will be found on line 11b.

 

Please attach a signed copy of your most recent tax return forms.

Option 2- Families that did not file a tax return will need to submit an Income Verification Form. You can access the form digitally here: https://smcc-ub-pub.studentaccess.com/appform/default.aspx?guid=967fd1f0-4997-48ba-8b67-ce38f93511fd

Review and Signatures/Other
Referral Source

Student Acknowledgements

My signature below indicates my understanding and agreement to the following:

  • All of the above information is true and correct to the best of my knowledge.
  • I am committed to achieving a four-year degree.
  • I agree to actively participate in SMCC’s Upward Bound program which includes: participating in tutoring sessions, weekly lunch meetings, enrichment sessions, field trips/tours, Saturday Academies, and attend the 6-week summer and residential program.
  • I understand that difficulty in making academic progress and not meeting the program requirements may result in possible probation/dismissal from the Upward Bound Program.
  • I give permission to have my name and/or picture published in any program marketing materials without any compensation of any kind or restriction of its use.
  • I authorize Upward Bound to have access to my school (academic/financial) records while in the program with respect to confidentially for program purposes only.
  • I understand that the program data collected is used for tracking and research purposes.
Student Signature *
Please select a signature verification type.

Parent/Guardian Acknowledgements

My signature below indicates my understanding and agreement to the following:

If selected, this is to authorize permission for my son/daughter to attend and participate in the Upward Bound Programing. Students have commitments during and after school and on weekends during the academic year and for 6 weeks in the summer. Programming is hosted at Central High School, Academies at South Mountain, South Mountain Community College, Northern Arizona University, and virtually as needed.

Furthermore, I authorize the Upward Bound program to obtain school documents which may include, but are not limited to: official transcripts, grade point average, ranking in class, standardized test scores including the AIMS, PLAN, PSAT, ACT, SAT his/her middle school transcripts, class schedules, school lunch program eligibility, and any other information used to determine academic, career, or college progress.

I hereby release, discharge and agree to hold harmless South Mountain Community College (SMCC), its legal representatives or assignees, and all persons acting under its permission or authority or those for whom it is acting, from any liability after all Upward Bound activities have been completed or finished. At the conclusion of every activity and/or event, all students will be dismissed by SMCC staff. Upon dismissal, students become the sole responsibility of the parent/guardian. No supervision will be provided once the students are released from any and all Upward Bound activities. It is the parents’ responsibility to ensure that their son/daughter has made appropriate transportation arrangements and is picked up within a reasonable amount of time.

Parent/Guardian Signature *
Please select a signature verification type.

Maricopa County Community College District (MCCCD) is an EEO/AA institution and an equal opportunity employer of protected veterans and individuals with disabilities.  All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, or national origin. A lack of English language skills will not be a barrier to admission and participation in the career and technical education programs of the college.

The Maricopa Community Colleges do not discriminate on the basis of race, color, national origin, sex, disability or age in its programs or activities.  For Title IX/504 Concerns, call the following number to reach the appointed coordinator:  (480) 731-8499.  For additional information, as well as a listing of all coordinators within the Maricopa College system, visit the following weblink:  https://distict.maricopa.edu/consumer-information/non-discrimination-statements.