Upward Bound Application

Thank you for your interest in Upward Bound.

The Upward Bound Program is funded under the U.S. Department of Education. The program was launched in 1965 after the passage of the Economic Opportunity Act of 1964. It is the first federal college access program.

Upward Bound provides opportunities for participants to succeed in their precollege performance and ultimately in their higher education pursuits. The goal of Upward Bound is to increase the rate at which participants complete secondary education and enroll in and graduate from institutions of postsecondary education.

The Upward Bound Program at Chaffey College assists low-income (based on Federal TRIO Program Levels), potential first-generation college graduates (neither parent holds a bachelor's degree), and educationally at risk students who are currently attending A.B. Miller High School or Fontana High School in the Fontana Unified School District in Fontana, California.

THERE IS NO COST TO PARTICIPATE.

In order to be considered for the Upward Bound programs, students must submit a COMPLETE application and meet the eligibility requirements established by the U.S. Department of Education.

Most of the application can be completed online with the help of a parent or guardian. You may save and go back if you don't complete it at one sitting.

The personal information, including financial information and educational attainment provided in this application is gathered for reporting purposes with the U.S Department of Education. This information is required to determine if the student meets federal eligibility requirements.

Questions? Please contact us:

Elizabeth C. Almanza, Director - elizabeth.almanza@chaffey.edu

Janice Frith, Advisor - janice.frith@chaffey.edu

Please note, completing this application and/or satisfying the eligibility criteria below is only part of the selection process and does not guarantee admission into the Upward Bound program at Chaffey College.

PARENT/GUARDIAN INFORMATION

Parent/Guardian Full Name 1*

First Name

Last Name

Relation to Student*

Father Mother Foster Parent

Other:

Mobile Phone Number*

Preferred Language:*

Email*

Highest Level of Education for Parent/Guardian 1*

Parent/Guardian Full Name 2*

First Name

Last Name

Relation to Student*

Father Mother Foster Parent

Other:

Mobile Phone Number *

Preferred Language*

Email Address*

Highest Level of Education for Parent/Guardian 2*

INCOME INFORMATION

Number of People in Household (including yourself)*

Did your parent(s) file a Federal Income Tax Return during the last calendar year?*

Please note that participants cannot begin services until program has recieved financial document for eligibility verfication.

What was your parent(s) taxable income for the most recent Tax Return?*

(Taxable Income can be found on the federal income tax return. On the IRS Form 1040 see line 15).

You indicated above that your parent(s) DID NOT file a tax return for the last calendar year. Please select one of the following:*

What was your parent(s) total income for the last calendar year?*

Is your family currently receiving any of the following Public Assistance (Check All that Apply):*

Cal Fresh/Supplemental Nutrition Assistance Program (SNAP) CalWORKS/Temporary Assistance for Needy Families (TANF) Medi-Cal Supplemental Security Income (SSI)/Disability Unemployment (UI) None of the above

I understand that as a federal grant under the US Department of Education, the Upward Bound Program at Chaffey College must verify eligibility for all participants, including family income and family size.

I understand that I may be requested to provide income documentation if my son/daughter is admitted into Upward Bound program at Chaffey College.

By signing this application, I hereby certify that all information provided on this application is true and correct. I understand that a false statement or misrepresentation will make the applicant ineligible for the Upward Bound Program at Chaffey College.

Parent Signature

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RELEASE & CONSENT FORM

I understand the purpose of the Upward Bound Program, a federal program aimed at preparing participants to successfully complete a program of postsecondary education and willfully consent to having my child participate.

Authorization is hereby given to the Upward Bound Program at Chaffey College to request and service the information listed below from the Fontana Unified School District, Chaffey College and the National Student Clearinghouse.

Class schedule
Academic Transcripts with current standardized test scores
Current cumulative records
Access to the FUSD student/parent online portal
PSAT/SAT/ACT Test Scores
Postsecondary Educational Enrollment Verification

These records will be used for the following purposes

To determine academic need and program eligibility
To create Individual Development Plan
To monitor and track student progress
To provide information to the U.S. Department of Education per grant guidelines in the Annual Performance Report

I understand and agree that the Upward Bound Program at Chaffey College will not allow a third party to have access to this information without the written consent of the parents/legal guardians.

I consent to having my child participate in site visits and virtual appointment by Upward Bound Staff for advising purposes.

I understand that by signing this form, permission is granted to use photos of the participant on program brochures, flyers and website. In addition, Chaffey College may also wish to use my child’s photograph, voice or student work for promotional and educational reasons, such as publications, posters, or at community fairs.

I understand that the Upward Bound Program at Chaffey College must monitor my child’s academic progress from the date of acceptance into the program through high school graduation and until completion of a bachelor’s degree.

I understand that the Upward Bound Program is a federally funded college prep program and that my selection to participate in the program is based on my meeting the federal eligibility criteria.

I understand that the probationary period for an Upward Bound student is 60 days during the academic year and 10 days during the summer. During this period, if I fail to actively participate in every aspect of the program, I may be dropped from the program at the close of the probationary period.

I understand that future enrollment in the program is based on my participation and academic progress.

Parent Signature

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WAIVER OF LIABILITY FORM - CHAFFEY COMMUNITY COLLEGE DISTRICT

Participant's Name*

First Name

Initial (optional)

Last Name

Name of Class or Activity: Upward Bound Program, Chaffey College

Waiver: In consideration of being permitted to participate in any way in the Upward Bound Program, a federally funded TRIO program at Chaffey College until completion of high school.

Hereinafter called the “Activity”, I, on behalf of myself and my minor child and for myself, my heirs, personal representatives or assigns, do hereby release, waive, discharge, and covenant not to sue the Chaffey Community College District, its officers, employees, and agents from liability from any and all claims including the negligence of the Chaffey Community College District, its officers, employees and agents, resulting in personal injury, accidents or illnesses (including death), and property loss arising from, but not limited to, the participation by my minor child in the Activity.

Assumption of Risks: Participation in the Activity carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. The specific risks vary from one activity to another, but the risks range from 1) minor injuries such as scratches, bruises, and sprains 2) major injuries such as eye injury or loss of sight, joint or back injuries, heart attacks, and concussions to 3) catastrophic injuries including paralysis and death.

Indemnification and Hold Harmless: I also agree to INDEMNIFY AND HOLD CHAFFEY COMMUNITY COLLEGE DISTRICT HARMLESS from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorney’s fees brought as a result of my minor child’s involvement in the Activity and to reimburse them for any such expenses incurred.

Severability: The undersigned further expressly agrees that the foregoing waiver and assumption of risks agreement is intended to be as broad and inclusive as is permitted by the law of the State of California including Education Code Section 72640 and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

Acknowledgment of Understanding: I have read all previous paragraphs, including the waiver of liability, assumption of risk, and indemnity agreement, know, fully understand its terms, acknowledge these and other risks that are inherent to the Activity, and understand that I am giving up substantial rights, including my right to sue on behalf of myself or my minor child. I acknowledge my participation is voluntary, that I knowingly assume all such risks, and that I am signing the agreement freely and voluntarily, and intend by my signature to be a complete and unconditional release of all liability to the extent allowed by law.

In the event of any illness or injury, I give full authority to the district staff to obtain such medical treatment and/or surgery from a licensed physician/surgeon, paramedic or hospital as deemed necessary for the welfare of my child.

I acknowledge that I fully and completely understand the potential risks that may be associated with this Activity and that my child’s participation is strictly voluntary.

Students Date of Birth*

Student Signature*

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Date*

Parent Signature*

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Date *

Full Name Parent/Legal Gardian*

First Name

Last Name

STUDENT EXPECTATIONS

As a participant I will:

Commit to being an active participant of Upward Bound with a minimum of 80% participation.
Communicate to staff in a timely manner if I am unable to attend an event, program or service.
Be respectful of the staff, peers, presenters and spaces we occupy.
Work with other students and Upward Bound staff to resolve any conflicts that may arise and communicate with staff about specific concerns and share any suggestions for improvement.
Attend school on a regular basis, be attentive in class and make an effort to understand the material.
Enroll in A-G College Prep courses at your high school and maintain a minimum 2.5 Grade Point Average (G.P.A) in coursework with grades of C or better or be at risk of being placed on academic probation or program dismissal.
Attend tutoring at my high school if my GPA from the previous semester fell below a 3.0 and/or if I received a D or F in any A-G course or if I am a new student on probation.
Attend academic advising sessions with the Academic Advisor at least once per month.
Attend and actively participate in our monthly Saturday Academy sessions throughout the academic year.
Attend Summer Academy each summer (unless remediating a course at your high school).
Apply for admission to college the fall of my senior year in high school.
Apply for the Free Application for Federal Student Aid (FAFSA) my senior year in high school.
Update Staff with changes to contact info such as mailing address, phone number, email and FUSD portal.
Enroll in a community college or university directly following high school graduation.
Maintain communication with Upward Bound up to six years after graduation for federal reporting requirements.

Student Signature*

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As a parent I will support my child if chosen as an Upward Bound participant by:

Ensuring my child attends activities, including advising, Saturday Academy Sessions, fields trips, tutoring, workshops, and Summer Programs.
Attending Orientations, Family Workshops and other Upward Bound programs when possible
Maintaining contact with Upward Bound staff and providing updates or any special needs or circumstances about my child that can assist in better delivery of services
Encouraging my child to do their best in school and remind the scholar that college is a part of their future.
Supporting my child to participate in learning opportunities, such as summer programs, competitions, etc.
Providing transportation to and from the program - and ensuring that my child arrives on time and is picked up promptly.
To communicate with the program in writing about any special needs or circumstances. For example, if a student attending alone needs to leave early, please send a note.

Parent Signature

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PERSONAL STATEMENT

Description Area

Why do you want to participate in the Upward Bound Program at Chaffey College? *

Please write at least 3 sentences. Minimum 200 characters.

What are your educational and career goals? *

Please write at least 3 sentences. Minimum 200 characters.

Describe the world you come from — for example, your family, community or school — and tell us how your world has shaped your dreams and aspirations. *

Please write at least 3 sentences. Minimum 200 characters.

Tell us about a personal quality, talent, accomplishment, contribution or experience that is important to you. What about this quality or accomplishment makes you proud and how does it relate to the person you are? *

Please write at least 3 sentences. Minimum 200 characters.

What do you feel is the greatest academic challenge you face?*

Please write at least 3 sentences. Minimum 200 characters.

RECOMMENDER INFO

Please include the name and email address for one reference that can complete a recommendation form for you. This can be a teacher, coach, counselor, etc. Once you submit your application we will send your recommender an email with the link to complete a form online. Please note that the recommendation form is used to determine need for support and services and not eligibility.

Name of Recommender:*

Recommender's Email Address: *

Relationship to Student:*

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