Community College of Philadelphia TRIO Upward Bound Program Application

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Student Information

First Name *

Last Name *

Date of Birth *

Month

Day

Year

Gender

High School *

Current Grade *

High School Student ID #

Address *

City *

Zip Code *

Home Phone Number *

Student Cell Number

Email Address *

Please indicate your citizenship status *

** This information is not used to determine your eligibility for the program **

Please indicate your race/ethnicity (check ALL that apply)

Please indicate your race/ethnicity (check ALL that apply) Other...

Parent/Guardian 1 Information

First Name *

Last Name *

Relationship to student *

Address *

City *

Zip Code *

Home Phone Number *

Parent/Guardian Cell Number *

Parent/Guardian 2 Information

First Name

Last Name

Relationship to student

Address

City

Zip Code

Home Phone Number

Parent/Guardian Cell Number

Eligibility Form and Income Verification for Parents and/or Guardians

According to the United States Department of Education, in order to be eligible for TRIO Upward Bound participation a student must be from a low-income household OR a family where neither parent has a 4-year Bachelor’s degree OR be at academic risk for failure.

The information that is requested in this application will be treated in a confidential manner. This portion of the application must be completed by a Parent/Guardian.

Household Income Information

Including yourself, please give the total number of people in your household *

Please check next to your household taxable income (found on line 11b of your IRS 1040 tax form or IRS 1040-SR tax form) *

For income verification, please include a copy of either if available • Parent/guardian’s most recent 1040 tax form, • Proof of public assistance (access card), • Proof of social security, or • Other benefits

Parent's Educational Attainment Information

Please check what best describes your educational background

Mother *

Father *

I declare that the information provided on this application reflects my true family size, income level and parent/guardian’s educational background.

Leave this field blank

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Community College of Philadelphia TRIO Upward Bound Program Application