Central College Upward Bound I

New Student Application for FALL ADMIT 2020-2021


Last Name *
Middle name or Initial *
First Name *
Address *
City *
State *
Zip *
Social Security Number *
Birthdate (mm/dd/yyyy) *
Place of Birth *
Student Is:
US Citizen
Becoming a Citizen or Permanent Resident
Highschool *
Current Grade *
Projected Date of H.S. Graduation (month/year) *
Student Cell Phone Number *
Student Email *
T-shirt Size *
Are you currently a participant in:
Science Bound
Upward Bound - Simpson
Upward Bound - DMACC
Do you identify as Hispanic/Latino?  1=Yes  2=No
Ethnic (Hispanic) *
Please also choose which racial groups you most identify with (even if you also identify as Hispanic or Latino).   1=Yes  2=No
American Indian/Alaskan Native *
Asian *
Black or African American *
White *
Native Hawaiian or Other Pacific Islander *
Has the student ever been convicted of a felony? *
Has the student ever been convicted of any offense that places you on the Sex Offender Registry in Iowa or any other state? *
Do you have any summer plans/activities that would cause you to miss more than one class day during the 2021 summer session June 6-July 2? If so, explain. *


I hereby apply for admission to the Central College Upward Bound (CCUB) program. I certify all information provided herein is true and accurate to the best of my knowledge. I understand that knowingly providing inaccurate or incomplete information may result in expulsion from the program.

I understand CCUB is an academic program designed to help students develop the knowledge, skills, and attitudes necessary for the pursuit of education beyond high school. I understand if admitted, I will be expected to participate fully in BOTH the six-week summer residential program and the academic year program of activities organized for program participants. CCUB activities in the summer and academic year may include academic instruction, workshops, field trips (within or outside Iowa), cultural events, tutoring, conferences, social events, community service, or physical activities. Failure to participate at acceptable levels may result in the loss of stipends, suspension, or expulsion from the program. I have been informed that additional benefits to program participation include:

  • Room, board, transportation, and will be eligible to earn up to $120.00 in stipends during the summer session, June 6-July 2.
  • Up to $40.00 per month stipend during academic year, transportation to workshops, field trips, college visits, cultural events, and tutoring as needed during the academic year. (Stipend amounts are dependent on academic performance, behavior, and/or program participation.)

I agree to abide by all CCUB policies and rules as established to create a safe, welcoming, and positive learning environment.

I understand and agree to abide by the following CCUB policy regarding the use of tobacco, alcohol, and/or illegal drugs: CCUB participants, regardless of age, may not possess, use, or distribute to others tobacco products, alcohol, or illegal drugs. Students violating this policy will be subject to suspension or expulsion from the program.

Signature of Student *
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Signature: (Type in your full name)
I agree to the terms included.
Signature of Parent or Legal Guardian *
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Signature: (Type in your full name)
I agree to the terms included.
Date *


The United States Department of Education requires each UB program to select two-thirds of program participants from families whose taxable income is at or below federal income guidelines that are set annually by the Department.  The information requested in this form documents participant eligibility and will be kept strictly confidential.

Please upload a copy of Page 1 and Page 2 of your completed 2019 federal tax form 1040
Family Income/Self Reported

Using your 2019 federal tax form please indicate the number of exemptions, which is equal to your number of dependents plus person filing the tax form plus spouse (if filing a joint return) as well as your taxable income, which is the amount on Line 11b from form 1040.

If you submitted a copy of your tax forms in Section A, please enter NA for the next two questions.

Number of Exemptions *
2019 Taxable Income *
I submitted my tax forms in section A, therefore I entered NA in this section.. Please answer YES or NO *
Financial Assistance
Check all that apply:
Applicant resides in a foster home
Applicant does not reside with a natural or adoptive parent
Food Stamps Case
Food Stamps Case #