Thank you for your interest in Upward Bound at Mineral Area College.  You cannot save and restart this application so be sure to have your 2023 taxable income from LINE 15 of your 2023 tax form available before you start.  A parent signature is also required. For questions or assistance call (573) 518-2156.

Upward Bound Application
First Name *
Middle Name *
Last Name *
LEGAL Gender *
Date of Birth *
School District *
Grade *
Address *
City *
State *
Zip Code *
Cell Phone Number
Who do you live with?
Contact 1 Name *
Relationship to student *
Cell Phone Number
Home Phone Number
Work Phone Number
 
Name (Adult 2)
Relationship to student
Cell Phone Number

List someone outside of your household we could contact in case of an emergency.
Name
Relationship to student
Cell Phone Number
Eligibility
Are you a United States citizen? *
If you are not a citizen, list status
Does the student's natural or adoptive parent have a bachelors (4 year college) degree? *
If yes, list the person with degree, type of degree, and name of college that issued the degree.
Did you file your 2023 federal tax return? *
What is the amount listed on LINE 15 of your 2023 federal tax form? This is your taxable income. *

How many people are living in your home ? The student should be included. *
List everyone who lives in your home and their relationship to the student (example:  John Smith - father, Jane Smith - mother).
Are you an orphan?
Are you a ward of the court?
If yes, what circuit or county?
Teacher Information
Please give the names of your math, science, and English teachers below.
Math Teacher's Name
Science Teacher's Name
English Teacher's Name

Academic Support

Select at least one of the options to show that you need academic support.
1.) *
2.)
3.)
Other:
Sign and Date
I certify that the income, education and household information are true and correct and understand that deliberate misrepresentation of the information may result in prosecution under applicable state and federal laws. I also agree to the records release stated below.

A.    High School Records Release

  The student named below is applying for acceptance into the Upward Bound program. I hereby authorize release of transcripts, test scores, attendance, discipline records, IEP, 504 and other pertinent reports since grade 7 pertaining to my child's academic progress in school to the Upward Bound project at Mineral Area College.

B.    Future Follow-Up Activities Release

  If the student named below is selected for participation in Upward Bound, I hereby authorize the school to release the same information annually to the Upward Bound project. I further authorize the release of each semester's class schedule, a final transcript verifying graduation, and other pertinent information. The school can continue to provide the requested information until I rescind this permission in writing or until one year after the student graduates.

C.     College Records Release

  The federal government requires Upward Bound to track participants through the completion of their post-secondary education. I give my permission to any college I attend or have attended to provide proof of attendance, transcripts, FAFSA information, and any degrees completed to the Upward Bound project at Mineral Area College.
Student Signature:
*
Signature Type: Simple    Start Over
Click here to start signing.
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Signature: (Type in your full name)
I agree to the terms included.
Date (MM/DD/YYYY) *
Guardian/Parent Signature: 
*
Signature Type: Simple    Start Over
Click here to start signing.
  • Pencil
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Signature: (Type in your full name)
I agree to the terms included.
Date (MM/DD/YYYY) *
Other Information - Optional
TO BE COMPLETED BY PARENT OR GUARDIAN ABOUT YOUR STUDENT.
Is your ethnic group Hispanic/Latino?
Are you
White
Asian
Black or African American
American Indian/Alaskan Native
Native Hawaiian or Other Pacific Islander
Race Unknown
Is English the primary language you speak at home?
If no, list primary language.
Do you have a physical handicap?
If yes, please describe.
Are you homeless?
Do you have an Individualized Educational Plan (IEP) or receive special services at your school?
If yes, please describe.
Have you been involved with the juvenile justice system?
If so, list date and incident
Do you have a diagnosed learning disability?
If yes, please describe.
Are you in foster care?