Household Information


The Upward Bound Math & Science Program is a FREE, year-round, college preparatory program funded by the Department of Education and sponsored by Fitchburg State University. Our program provides academic support for high school students through tutoring services, STEM and college prep workshops, college visits, and more! Eligibility is based on first generation college status, family income, and academic motivation. To be eligible for admission and participation, students must meet the following requirements: be the first in their family to complete a 4-year college degree AND/OR come from a moderate income background (each as defined by the U.S. Department of Education) demonstrate academic need reside in the program's target area (Fitchburg and Leominster) be a U.S. Citizen or permanent resident Application Process: Submit the Application Part 1: Student Information (to be completed by the student) Submit the Application Part 2: Household Information (this form) Upward Bound staff will review all completed applications for initial eligibility. Students determined to be eligible will be invited to interview with a program staff member. Following the interview, staff will work with the student to request and obtain a teacher recommendation and any additional documentation. APPLICATION PART 2: HOUSEHOLD INFORMATION To be completed by the parent/guardian. All fields of the application are required to determine program eligibility. Information provided is protected by the Privacy Act. Student Information
First Name *
Preferred Fist Name
Legal Middle Name or Initial *
Legal Last Name *
Parent/Guardian Information Parent/Guardian 1 (must be someone at the student's primary residence)
First and Last Name *
Relationship to Student * Father Mother Grandfather Grandmother Aunt Uncle Brother Sister Friend Spouse
Phone *
Email Address *
Highest Education Level Completed * 8th grade Attended high school but did not receive a diploma GED or equivalent High school diploma Attended some college, but did not receive a degree Post secondary certificate Associates degree Bachelors degree Graduate degree (masters or doctorate) Other
Occupation *
Parent/Guardian 2
First and Last Name
Relationship to Student Father Mother Grandfather Grandmother Aunt Uncle Brother Sister Friend Spouse
Phone
Email Address
Highest Education Level Completed 8th grade Attended high school but did receive a diploma GED or equivalent High school diploma Attended some college but did not receive a degree Post secondary certificate Associates degree Bachelors degree Graduate degree (masters or PhD) Other
Occupation
Household Information
With whom does the student live primarily? * Both biological/adoptive parents One biological/adoptive parent One biological/adoptive parent + step-parent Legal guardian(s) Foster parent(s) Student is homeless
How many people live in the student's primary household? (including the student) *
In the space below, please list the names, ages, and the relationship to the student of the individuals living in your primary residence. Example: Susan Smith (sister, 8) Do not include the student or the Parent(s)/Guardian(s) listed above.
Full name (relationship, age) *
Household Income Please complete the following questions necessary to determine income eligibility for the Upward Bound Programs. The questions relate to Parent(s)/Guardian(s) with whom the student primarily lives (those who are listed above). Note: If you are unable to upload income verification documents while completing this form, please continue and submit the application. After receiving your application, a staff member will contact you for alternative methods for submitting tax returns, statements, etc.
Are/were you required to file a 2023 Federal Income Tax Return (1040)? * Yes No N/A, student is a ward of the court/state, in foster care, or homeless
If yes, please list the Taxable Income from 2023 (IRS Form 1040, line 15)
Please upload a copy of your 2023 tax return(s) for verification.
If no, what were the type and value of the household's income sources in 2023?
Please upload a copy of statements verifying the above income sources.
Additional Documents Note: If you are unable to upload any documents while completing this form, please continue and submit the application. After receiving your application, a staff member will contact you for alternative methods for documents. Student Health Insurance
Insurance Provider *
Please upload a copy/photo of the students insurance card.
Social Security Card
Please upload a copy/photo of the students social security card.
AUTHORIZATION TO RELEASE INFORMATION By signing below and submitting this application, I hereby authorize any educational institution that my student attends or will attend to release the following academic record information to the Fitchburg State Upward Bound Math and Science Program: grades transcripts course schedules attendance records disciplinary records individual education plans and 504 plans standardized test scores proof of graduation proof of enrollment academic progress toward graduation financial aid I understand that the United States Department of Education requires Upward Bound Programs to report on students' academic eligibility and progress from point of admission through either their graduation from college or for at least six years after graduation from high school, and that this information will be handled in strict confidence according to federal regulations. CERTIFICATION All of the information in this application is true and correct to the best of my knowledge. If asked by an authorized official, I agree to give proof of the information provided on this application.
Parent/Guardian Signature * Signature Type: Simple Start Over Signature: (Type in your full name) I agree to the terms included.