Upward Bound Application s1

**Confidential**

Student Application for:

UPWARD BOUND

Shasta College Upward Bound is a year-round program geared toward students who are currently in 9th, 10th or 11th grade with academic potential and interest in pursuing a college education.

APPLICATION DEADLINE:

Now Serving Foothill H.S., Central Valley H.S.

and Enterprise H.S.

Sylvia Ruano

Project Director

Shasta College Upward Bound

1400 Market St., Office 8116 • P. O. Box 496006
Redding, CA 96049-6006 • 530-339-3604

Intake Information

To parent or legal guardian: The personal information, including financial status and educational levels, given to the Upward Bound Projects is used for reporting purposes with the United States Department of Education. No one may access, view or utilize the information unless they work with or for Upward Bound, at Shasta College or unless they are given specific or legal authorization to said information. This information is required to determine if your child meets federal eligibility guidelines established by regulation of the United States Department of Education. All information is protected under the Family Educational Rights and Privacy Act (FERPA, 20 USC 1231a).

Legal Name of Applicant

FIRST MIDDLE LAST

Name of Parent(s)/Guardian

Mailing Address City Zip

Home Phone Birthdate c Male c Female

Social Security Number ccc cc cccc Birthplace

Email Address Cell Phone Number

What languages are spoken in your home?

What is the preferred language of your parents or guardians?

Current School Grade Counselor

Are you currently a participant of: c Upward Bound c Educational Talent Search c GEAR UP

If yes, name and phone number of program director

NAME PHONE NUMBER

Ethnicity: c African-American c Caucasian/White c Native American

c Asian c Mexican American/Latino c East Indian

c Other/______

Are you a US Citizen? c Yes c No

If you are not, are you a Resident Alien? c Yes c No

NOTE: You must be a US citizen or legal resident of the United States in order to participate in and receive services from Upward Bound. If you are not a US citizen, enter your Alien Registration Number. If your number is only eight digits, enter a zero after the “A”.

How did you hear about Upward Bound?

Shasta College Upward Bound

1400 Market St., Office 8116 • P. O. Box 496006
Redding, CA 96049-6006 • 530-339-3604

TRiO Upward Bound is a Federal Department of Education grant sponsored by Shasta College

Parent and Family Information

Please give the name(s) of the people who are living in your home (add additional piece of paper if necessary).

NAME RELATION AGE NAME RELATION AGE

Is your birth or adoptive father living in the home? c Yes c No Name

Is your birth or adoptive mother living in the home? c Yes c No Name

Legal guardian(s) name(s)

Circle the highest year in school/college completed by your male parent or legal guardian:

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17+

Degrees earned (Check all that apply) c HS Diploma c Associate’s c Bachelor’s c Other

Circle the highest year in school/college completed by your female parent or legal guardian:

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17+

Degrees earned (Check all that apply) c HS Diploma c Associate’s c Bachelor’s c Other

Medical History of Applicant – to be filled out by parent or legal guardian

In order to ensure the safety and well-being of your child, please be specific when answering questions.

Physician/Clinic Name phone number______

Is your child presently under a physician’s care? ¨ Yes ¨ No If yes, why?

Are there limits on your child’s physical activities? ¨ Yes ¨ No If yes, explain

Does your child have allergies (i.e., to medications, insects, etc.)? ¨ Yes ¨ No If yes, explain

Does your child have medical problems, or has (s)he been seriously ill in the past 3 years? ¨ Yes ¨ No If yes, explain

Is your child covered by medical insurance? ¨ Yes ¨ No

Can your child swim? ¨ Yes ¨ No

If there is an emergency and we cannot contact you, who should be called?

Name Telephone # Relation

ESSAY QUESTIONS (REQUIRED)

Use additional paper if necessary

1. Introduce yourself: Tell us about your home life, where you live, or your cultural background. Do you have any special interests or hobbies? Of what past accomplishments are you most proud of?

______
______
______
______

______

2. Discuss your educational history: What has school been like for you? How do you feel about education? What do you think about your grades? Do they reflect your potential?

______
______
______
______

______

3. Discuss the future: What are your thoughts about college? Do you have any career plans at this time? Discuss factors that might make going to college difficult for you.

______
______
______
______

______

4. Explain why you want to participate in the Upward Bound Program. What you would like to accomplish or learn through the program and what you hope to get out of it?

______
______
______

______

Shasta College Upward Bound

1400 Market St., Office 8116 • P. O. Box 496006
Redding, CA 96049-6006 • 530-339-3604

c Transcript Release Authorization

My child’s school has my permission to release grades, records and test scores to the Upward Bound Project at Shasta College.

c Field Trip Release Authorization

My child has my permission to participate in field trips planned and supervised by the Upward Bound staff, at Shasta College. The programs, Shasta College and the employees are released by me from claims against them arising from injuries, which might occur en route to/at/from the destination.

c Information/Photography Release Authorization

I give permission to Upward Bound, at Shasta College, to use, release and publish information about or photographs of my child. I trust that the information and/or photographs will only be released when it is in the best interest of my child, or the Upward Bound Projects in general, or when the recipient has a legal “need to know” as prescribed in the FERPA and the US Department of Education regulations.

c Medical Release to be signed by Parent or Legal Guardian

Should (print child’s complete name) require medical attention and/or care while under the supervision of Upward Bound, at Shasta College, I give my consent to medical examinations and necessary treatment, including drugs and x-rays, as may be deemed advisable by the attending physician. This consent shall be in effect so long as my child is a participant in UB. If an emergency arises requiring major surgical procedures, the director or another staff member will attempt to reach me and be guided by my wishes. In the event that I cannot be contacted, the attending physician has my consent to act as medical judgment may dictate.

______

Student Signature Date

______

Parent/Guardian Signature Date

Shasta College Upward Bound

1400 Market St., Office 8116 • P. O. Box 496006
Redding, CA 96049-6006 • 530-339-3604

Educational, Career and Extracurricular Information

Educational Plans – Check the statement(s) which best describe(s) your present plans:

¨ I plan to work during both the school year and summer.

¨ I plan to work only during the summer.

¨ I plan to work only during the school year.

¨ I plan to go to work full-time after high school graduation.

¨ I plan to enter military service after high school graduation.

¨ I plan to complete an associate’s degree (2 years of community college) after high school graduation.

¨ I plan to complete a bachelor’s degree (4 years of university) after high school graduation.

¨ I am currently undecided about my educational plans after high school graduation.

Educational Plans – List in order of preference, two occupations you think would best fit your abilities and interests if you were given the necessary education and required training:

1. 2.

Tutoring will be made available and is highly recommended. Are you willing to participate? If not, please explain

Shasta College Upward Bound Summer Program will include a 3 week day program and a 3 week residential program, are you interested in participating? If not, please explain

I would like help with/information about – Please check all that applies:

¨ College Preparation (classes, tests, etc.)

¨ Paying for College (Financial Aid/Scholarships)

¨ Choosing a Career

¨ Setting Goals

¨ Study Skills

¨ Test Taking Skills

¨ Becoming a Tutor/Mentor (Subject:______)

¨ Getting a Tutor/Mentor (Subject: ______)

¨ Getting involved in School/Community Activities

¨ Other: ______

Upward Bound serves students from the time they are admitted to the program until high school graduation. Will you commit to participate in the program for that time period?

______Yes ______No

Upward Bound is a year-round program. Are you willing to participate in:

Contacts during school time? ______Yes ______No

Tutoring/homework assistance? ______Yes ______No

1-2 Saturday activities each semester? ______Yes ______No

(Field trips, leadership, workshops)

6-week summer program at Shasta College? ______Yes ______No ______Undecided

RECOMMENDATION FORM

Student______Grade______

Teacher Title (subject taught)

To the student: This form needs to be completed by a teacher or counselor.

To the teacher/counselor: Upward Bound is designed to prepare and motivate students with academic potential for success in postsecondary education. Your evaluation of the nominee is extremely beneficial to us in determining if the student will succeed in this highly intensive program. Please rate the student on each of the following areas of personal competence. If you would like to add additional comments or special considerations on why this student should be accepted, please feel free to continue on the back. Thank you!

Does this student have a positive attendance record? ______

Has the student had any disciplinary problems? ______

Are there any barriers of which you are aware that would prevent the student from going to college?

______

Based on your interactions and observations, check the box that best describes the student

Completes assignments, fulfills contracts ¨ Above Average ¨ Average ¨ Below Average ¨ N/A

Assumes responsibility ¨ Above Average ¨ Average ¨ Below Average ¨ N/A

Is motivated to achieve ¨ Above Average ¨ Average ¨ Below Average ¨ N/A

Has good work habits; is disciplined ¨ Above Average ¨ Average ¨ Below Average ¨ N/A

Has positive sense of self ¨ Above Average ¨ Average ¨ Below Average ¨ N/A

Is sensitive to the needs of others ¨ Above Average ¨ Average ¨ Below Average ¨ N/A

Has foundation in basic skills ¨ Above Average ¨ Average ¨ Below Average ¨ N/A

Demonstrates leadership skills ¨ Above Average ¨ Average ¨ Below Average ¨ N/A

Is emotionally mature ¨ Above Average ¨ Average ¨ Below Average ¨ N/A

Student has potential for postsecondary ¨ Above Average ¨ Average ¨ Below Average ¨ N/A

education

Signature Date

Please return to student for inclusion in application packet. A sealed envelope may be used.

Shasta College Upward Bound

1400 Market St. Office 8116 • P. O. Box 496006
Redding, CA 96049-6006 • 530-339-3604