Upward Bound APPLICATION

Upward bound APPLICATION

University of Colorado denver

TriO

Complete the entire application and return it to Upward Bound staff at your school (Jefferson and Sheridan High School only). Phone: 303.556.2322 E-mail:

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·  You must submit the following along with this application:

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¨  Student’s Counselor Recommendation

¨  Student’s Teacher Recommendations (2) from two teachers

¨  Student’s most recent CSAP/ACT Scores

¨  Unofficial copy of student’s transcript

¨  A copy of one of the following: Colorado issued ID, Social Security Card, Birth Certificate, Passport, Permanent Resident, or a letter of acceptance from INS

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Name: ______-_____-_____

First Middle Last Social Security Number

Mailing Address: Apt. No.

Street #, P.O. Box

City: ______State: Zip Code: Birthplace:

Gender: ¨ Male ¨ Female Birth date: ____/____/____ Home Phone #: ( ) _____-______

Student E-Mail: ______

Student Cell: ( ) _____-______Initial if UB may call/text this number

Parent or Guardian Initials

Parent E-Mail: ______

Parent Cell: ( ) _____-______Initial if UB may call/text this number

Parent or Guardian Initials

Ethnicity: Please make the appropriate selection:

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¨  American Indian/Alaskan Native

¨  Asian

¨  Black/African American

¨  Hispanic or Latino

¨  White

¨  Native Hawaiian or Islander

¨  Other: ______

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Are you a citizen of the United States? ¨ Yes ¨ No

Permanent Resident? ¨ Yes ¨ No Alien Registration Card #

Are you in Talent Search, another pre-college program or intend to apply to one? ¨ Yes ¨ No

If yes, which program?

What language is primarily your language? ¨ English ¨ Spanish ¨ Other:

Do you presently have a part time job? ¨ Yes ¨ No

If yes, answer the following: How many hours per week: ______

Check Day(s): ¨ Mon. ¨ Tues. ¨ Wed. ¨ Thurs. ¨ Fri. ¨ Sat. ¨ Sun.

academic INFORMATION

Are you committed to participate in individual tutoring sessions at your high school?

¨ Yes ¨ No ¨ Uncertain

Are you committed to participate in Saturday Academies at the University of Colorado Denver during the academic year? ¨ Yes ¨ No ¨ Uncertain

Are you committed to participate in a 6-week summer academic program at the University of Colorado Denver? ¨ Yes ¨ No ¨ Uncertain

Do you understand that, if accepted, the University of Colorado Denver Upward Bound Power-Up Program is an academic program that will track your academic progress beyond high school through your college education? ¨ Yes ¨ No ¨ Uncertain

Name of the high school that you are currently attending:

Year in School: ¨ FRESHMAN ¨ SOPHOMORE ¨ JUNIOR

Expected Graduation Year: Current Grade Point Average (GPA):

Your high school counselor’s name:

COURSES CURRENTLY ENROLLED IN TEACHER CURRENT GRADE

1.

2.

3.

4.

5.

6.

7.

Where are you planning on applying to college after graduation?

1. 2.

3. 4.

What will be your planned major?

(i.e. medicine, accounting, teaching, law, biology, etc.)

STUDENT AGREEMENT

If accepted into the program, I agree to accomplish the personal, academic, and college-preparation goals that Upward Bound Power-Up and I set for myself. I also agree to treat myself, other Upward Bound Power-Up students, and staff with respect, and to be a positive representative of the Program.

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Student Signature Date

FAMILY INFORMATION

Student’s parent(s) or guardian(s): Please provide the following information in order for us to better evaluate your son’s or daughter’s eligibility for Upward Bound. This information will be strictly confidential.

Has either parent received a bachelor’s degree from a U.S. college or University?

FATHER: ¨ YES ¨ NO MOTHER: ¨ YES ¨ NO

Taxable family income reported on Federal Income Tax Return during the most recent tax year:

$ ______

Total number of people supported by this income

Parent or Guardian initials

If you did not file an income tax return for the most recent year, please indicate your source(s) of income by placing a check beside the appropriate source(s).

¨ Social Security ¨ Welfare Benefits ¨ Veteran’s Benefits ¨ Unemployment

¨ Disability ¨ TANF ¨ Free or reduced lunch at school

¨ Other: ______

Will this year’s financial situation be significantly different from last year? If so please explain:

CERTIFICATION

The signatures indicate that to the best of our knowledge, the information provided on this application is true, complete and accurate.

As a parent/guardian signing this form, I give permission for my child to participate in all program sponsored activities. I also give permission to UB to track my student’s academic progress throughout my student’s high school and college education; and permission to use my child’s name and/or photograph for editorial, promotional, recruitment, or educational purposes. Shall my student be dismissed or withdrawn from the program; I will provide academic progress to the UB office.

______

Father’s Signature (Male Guardian) Date Mother’s Signature (Female Guardian) Date

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