Fillable UB Application Upward Bound Classic Application

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UB Application Upward Bound Classic Application

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The UB Application Upward Bound Classic Application form is 8 pages long and contains:

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17 check-boxes
232 other fields

Country of origin: US
File type: PDF

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Applicant: Please keep this page for your records

Pasadena City College

Upward Bound Program

1570 E. Colorado Blvd. D114, Pasadena, CA 91106

Tel. (626) 585-7696 Fax (626) 585-7969

Dear Applicant and Family:

Thank you for your interest in the Pasadena City College Upward Bound Program. Upward Bound is designed to

encourage students, from low-income families and/or whose parents did not graduate from a four-year college, to

develop the skills and motivation necessary for success in college and beyond. Students accepted into the program are

participants until they graduate from high school. All program services are free to participants. We expect students to

make a serious commitment to both their academic education and the Upward Bound program. Please make sure that

you complete the application and attach all required documentation (see below). All information provided on this

application is confidential and kept in a secure place.

Thank you,

The Upward Bound Staff

Application Checklist

For a complete Upward Bound application, please make sure you include the following:

 Complete Application- Sign and date (Please use blue/black ink to complete application)

 Two Letters of Recommendation (must be completed and signed by your high school teacher and high

school counselor)

 Student Questionnaire

 Copy of your signed social security card

 Copy of your U. S. birth certificate, U.S. passport or Alien Registration Card

 Parents Federal 1040 Income Tax form (a photocopy for the most recent tax year) and/or other required

income verification.

 Unofficial copy of transcript

Please submit completed application materials to:

Pasadena City College

Upward Bound Program

1570 E. Colorado Blvd. D114

Pasadena, CA 91106

If you have questions or need assistance filling out the application, please call the Upward Bound Program

office at (626) 585-7696.

Revised 09/01/2015 Page 1 of 3

Pasadena City College

Upward Bound Program

Application for Admission

1570 E. Colorado Blvd. D114, Pasadena, CA 91106

Tel. (626) 585-7696 Fax (626) 585-7969

Part I: Student Information

Instructions: Thank you for showing an interest in joining the Upward Bound Program. This application is our initial

introduction to you and will play an important part in considering you for the program. It is important that you and your

parent/guardian answer each question clearly and completely. Please use blue/black pen only. Please print legibly.

1. Today’s Date: ___________________________ 2. Social Security #: _______-______-_______

3. Name: _______________________________ _______________________________ ____________

Last First Middle Initial

4. Address: _______________________________________________________ _________________

Street Apt. #

______________________________________ ____________________________

City Zip Code

5. Home Phone: (____)__________________ 6. Student Cell Phone: (____)____________________

7. Student E-mail address: _________________________________________________________________

8. Gender: Male  Female 9. Expected Graduation Year: 20___________

10. Date of Birth: _______________________________ 11. Birth Place: ___________________________

12. Ethnicity (FOR STATISTICAL PURPOSES ONLY): 13. Current Grade Level:

 Hispanic  Incoming 9

grade

 American Indian/Native Alaskan  9

Grade  9

Grade

 Asian  10

Grade

 Black or African American  11

Grade  12

Grade

 White  12

Grade

 Native Hawaiian or Other Pacific Islander

 Biracial/Multiracial, specify_____________________

 Other, specify_____________________

Part II: Student Academic Information

14. Current School: ____________________________________________________________________

15. High School in Fall (If different from above): ____________________________________________

*Please note: Proof of enrollment may be required

16. Counselor’s Name/Phone Number: ___________________________________________________

17. Current Overall Weighted GPA: ______________________________________________________

Revised 09/01/2015 Page 2 of 3

Part III: Family Information

18. Father’s/Guardian Name: ________________

Occupation: _____________________________

Work Phone: _____________________________

Cell Phone: _____________________________

Living with Applicant:  Yes  No

19. Mother’s/Guardian Name: _______________

Occupation: _____________________________

Work Phone: _____________________________

Cell Phone: _____________________________

Living with Applicant:  Yes  No

20. What language do you primarily speak at home? _________________________________________

21. What is the number of people in your family/home? _____________________________________

Part IV: Eligibility Criteria-To be completed by Parent/Guardian

The U.S. Department of Education requires that Upward Bound gather this data in order to determine

student eligibility. Failure to provide the necessary supporting documents will prohibit your child form being

considered for admission. The personal information you give to the Upward Bound Program will be kept

confidential and is protected by the Privacy Act.

1. Citizenship Status: Is the student a

U.S. Citizen or  Permanent Resident: Alien Registration #A_____________

2. First Generation Status (Parents’/Guardians’ Educational Level):

Mother has a 4-year college degree (BA/BS) Yes No: Highest Grade Completed:____

Father has a 4-year college degree (BA/BS) Yes No: Highest Grade Completed:____

3. Income Status: Taxable parent/guardian income

a. Did you file a Federal Income Tax Return for previous year? Yes No

b. If you did not file a tax form for the last year or you are a recipient of public assistance,

please designate below the source and amount for any and all income you received

during the last year.

__ Self-Employment $______ __ Unemployment Comp. $_______

__ Soc. Sec. Benefits $______ __ Disability $_______

__ AFDC $______ __Other $_______

Supporting documentation is required, such as copy of award letter from AFDC, Social Security, verification

of income statement, etc.

4. Is student currently enrolled in anther TRIO Program such as a Talent Search or another

Upward Bound Program: Yes No If yes, Name of Program: _____________________

Revised 09/1/2015 Page 3 of 3

Part V: Authorization

1) All of the information I have provided on this application is accurate and correct.

2) Upward Bound (UB) is granted access to my student’s school(s) transcripts, standardized test scores,

SAT/ACT scores, and any other information which is necessary for participation of the student in the

UB program.

3) UB may use my student’s picture in program publication materials (brochures, web sites & displays).

4) Should my student require medical attention while participating in UB activities and I cannot be

contacted, I give my consent to medical examination and treatment deemed necessary by the attending

medical professional.

5) UB is granted access to student’s college enrollment, retention, and completion information.

6) UB is granted access to student’s financial aid information from colleges and the federal government.

7) We, the parent(s)/guardian of above stated student agree to encourage our son/daughter to attend

college immediately following high school graduation.

8) This authorization is valid with the application process, during high school and throughout the

student’s attendance in postsecondary education.

_______________________________ ______________________________ ________________

Parent/Guardian Name (Print) Parent/Guardian Signature (Date)

_______________________________ ______________________________ ________________

Student Name (Print) Student Signature (Date)

Part VI: Parent/Guardian-Student Agreement

If selected as a participant of the Upward Bound Program at Pasadena City College, I agree to

participate in the entire program, including the tutorial sessions, the Saturday sessions and the

summer program, unless other arrangements are made in advance with the Director or Educational

Advisor. If accepted, I will conduct myself in a manner that will bring credit to my family, my school,

community and myself. I also agree to abide by the rules and regulations established by the Upward

Bound Program during all program activities.

I also understand that the Director has the right to dismiss any student if the student does not adhere to

the rules and regulations of the program, if the student is not showing a positive attitude in participating in the

activities of the program or if there is a conflict between the student and the overall management of the

program.

I also understand that priority will be given to students that meet both the federal low- income guidelines

and that neither parents graduated from college.

_______________________________ ______________________________ ________________

Parent/Guardian Name (Print) Parent/Guardian Signature (Date)

_______________________________ ______________________________ ________________

Student Name (Print) Student Signature (Date)

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Pasadena City College

Upward Bound Program

1570 E. Colorado Blvd. D114

Pasadena, CA 91106

Tel. (626) 585-7696 Fax (626) 585-7969

Student Name ___________________________ Grade ______ High School _____________________

TO THE APPLICANT: After filling in your name, grade, and school, give this form to a teacher or

counselor who knows you well and can assess your academic achievement and potential for success in

completing high school and a post-secondary educational program.

DEAR TEACHER/COUNSELOR: This student has filed/will file an application with the Pasadena City

College Upward Bound Program. This college preparatory program is designed for students with

academic potential who need additional support in order to complete high school and enroll in a post-

secondary institution. Your valuable comments will assist the selection committee in making an informed

decision. If you have any questions, please call (626) 585-7696. Thank you for your assistance.

1. Please rate the student according to the criteria listed below.

Response Items

Low

Medium

High

Response Items

Low

Medium

High

Assertiveness

Initiative

Commitment

Respect

Leadership

Perseverance

Decisiveness

Study Skills

Motivation

Attendance

Self-Confidence

Maturity

Integrity

Empathy

2. Academic Strengths

______________________________________________________________________________

3. Academic Weaknesses

______________________________________________________________________________

4. Please describe specific activities, attitudes and abilities that appear to you to be especially

noteworthy.

_________________________________________________________________________________

5. How long have you known the applicant? _______________________________________________

6. In your opinion, this student (check one)

 Has the potential for success in a post-secondary educational program.

 At this time, the student has not yet exhibited potential for success in a post-secondary

educational program.

Name _____________________________________ Title _________________________________

Signature __________________________________ Date_________________________________

Rev. 09/2015

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