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VETERANS UPWARD BOUND PROGRAM
Application for Services
Today Is:
8/7/2025 1:12:15 AM
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(Required fields are marked with
*
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Personal Information
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First Name:
First Name is required!
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Last Name:
Last Name is required!
Middle Initial:
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Date of Birth:
Date of Birth is required!
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Social Security #:
Social Security # is required!
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Date of Application:
Date of ApplicationDate is required!
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Address:
Address is required!
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City:
City is required!
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State:
State is required!
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Zip Code:
Zip Code is required!
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County:
Make Selection
Douglas
Sarpy
Lancaster
Dodge
Email Address:
Day Phone:
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Cell Phone:
Cell Phone is required!
Evening Phone:
Emergency Contact Information
Name:
Phone:
Relationship:
Participant Demographics
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Employment:
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Unemployed
Part Time
Full Time
Retired
Employment is required!
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Disability:
Make Selection
Yes
No
Disability is required!
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Gender:
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Male
Female
Disability is required!
Race (Check all that apply):
American Indian/Alaskan Native
Black or African American
Native Hawaiian or other Pacific Islander
Asian
White
Hispanic/Lantino
Education
High School
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Have you completed High School?:
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H.S. Graduate
G.E.D. Graduate
Not Completed
High School is required!
Date of last enrollment:
Date:
School:
City:
Did you take the SAT and/or ACT?:
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SAT
ACT
SAT/ACT
N/A
What was your score?:
SAT Score:
ACT Score:
College
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Have you completed a college degree?:
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A.A./A.S
B.A./B.S
Currently Enrolled
Not Completed
Select Degree!
College, Degree Type, Program/Major:
Date of last enrollment:
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Do you have a defaulted student loan?:
Make Selection
Yes
No
Unsure
Student Loan is required!
What are your future education and career goals?:
Military Service
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Please Select Military Service:
I served on active duty as a member of the Armed Forces of the United States for a period of more than 180 days
I served on active duty as a member of the Armed Forces of the United States and was discharged or released because of a service connected disability
I was a member of a reserve component of the Armed Forces of the United States and was called to active duty for aperiod of more than 30 days
I was a member of a reserve component of the Armed Forces of the United States who served on active duty in supportof a contingency operation on or after September 11, 2001
Military Services is required!
Branch of Service:
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Air Force
Marine Corps
Coast Guard
Army
Navy
Reserve/NG
Military Discharge:
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Honorable
General
Bad Contuct
Dishonorable
Other than Honorable
Other
Specify Other discharge:
Date of most recent discharge:
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Are you eligible for G.I. education benefits?:
Make Selection
Yes
No
Not Sure
Are you eligible for G.I. education benefits is required!
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Do you have a disability related to your military service?:
Make Selection
Yes
No
Not Sure
Do you have a disability related to your military service is required!
First Generation Status
Did either parent or guardian with whom you resided have a bachelor’s degree prior to you turning 18?
*Please provide this information only for those parents/guardians living in your former household.
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Mother/Female Guardian:
Make Selection
Yes
No
Mother/Female Guardian is required!
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Father/Male Guardian:
Make Selection
Yes
No
Father/Male Guardian is required!
Income (Complete ONE of the two below)
Complete this item if you DID file a tax return last year.
I filed an income tax return last year. The number of individuals currently living in my household and/or claimed as dependents (including myself) is:
My total taxable income for last year was $:
(Form 1040 line 43 or Form 1040A line 27). Please note that taxable income is different from gross or net income.
*If available, please mail a copy of your 1040 or 1040A to our office as soon as possible.
Complete this item if you were NOT required to file a tax return last year.
I was not required to file a tax return last year. The number of individuals currently living in my household and/or claimed as dependents (including myself) is:
My total non-taxable income for last year (from all sources) was $
What Veterans Upward Services are you most interested in?
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Check all that apply:
Assessment of academic skills
Development of an education or career plan
GED completion
Assistance with financial aid and veterans’ benefits application
Referral to community/veterans’ agencies and supportive services
Assessment of career interests
Assistance with postsecondary school applications
Information about college degree plans and programs
Cultural and social opportunities
Study skills
College visits/tours
Please Select At least one!
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Academic Refresher courses:
Math
Science
Foreign Language
Composition
Literature
Reading
Computer
Financial Literacy
Please Select At least one!
Citizenship
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Are you a Citizen, National, or Permanent Resident of the United States?:
Make Selection
Yes
No
Citizenship is required!
If "no", do any of these situations apply?:
I am in the United States for other than a temporary purpose. Please provide evidence from the Immigration and Naturalization Service of your intent to become a permanent resident
I am a permanent resident of Guam, the Northern Mariana Islands, or the Trust Territory of the Pacific Islands.
I am a resident of the Freely Associated States – the Federated States of Micronesia, The Republic of the Marshall Islands, or the Republic of Palau.
HOW DID YOU HEAR ABOUT OUR VETERANS UPWARD BOUND PROGRAM?
Referral from community agency
Referral from veterans’ agency (VA, Vet Center)
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Our website
Referral from a school or educational institution
Word of mouth/walk-in
Referral from another TRIO project
Referral from non-TRIO program
Other
WHICH MCC VUB STAFF MEMBER ASSISTED YOU?
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James Hawthrone
Sharon Kramer
Elizabeth Vazquez
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Applicant Signature
I would like to participate in the Veterans Upward Bound program and receive the free services provided. I hereby certify that the information provided in this application is accurate and complete to the best of my knowledge.
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Applicant Signature:
Applicant Signature is required!
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Applicant Date:
Applicant Date is required!
CONSENT AND RELEASE FORM
I HEREBY GIVE MY CONSENT FOR Metropolitan Community College or its agency to use my name, likeness, photograph and/or comments. I understand these will be used exclusively for the College without compensation, be it publications, advertising, television, film, radio, Internet or other appropriate communication or educational media. I sign this of my own free will.
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Name:
Consent Name is required!
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Date:
Consent Date is required!
Address:
City:
State:
Zip Code:
Phone:
Email:
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Signature:
Consent Signature is required!