upward bound student application - Yuba College

Upward Bound Yuba College2088 N. Beale Road, TRiO/Cal-SOAP Office, Marysville, CA 95901 (530) 749-3858UPWARD BOUND APPLICATION PACKETStudent Name____________________________________________FirstLastGrade__________ School __________________________________Date:Dear Student Applicant,Thank you for your recent interest in the Upward Bound Program at Yuba College.If you are interested in participating in Upward Bound (UB), please fill out this application and return itto our office. You are responsible for making sure that your application is completed and turned inby the deadline.DOCUMENTS REQUIRED FOR THE UPWARD BOUND STUDENT APPLICATION: Eligibility Form Complete Application Packet Referral/Recommendation form (from school counselor, principal, teachercivic or church leader) Current Class Schedule, Transcript and Test Scores (request from your school) Copy of prior year Income Tax Return or DHS verification of incomeReturn ALL OF THE ABOVE to the counseling office at your high school or mail the entireapplication to the Upward Bound office at:UPWARD BOUNDYUBA COLLEGE2088 NORTH BEALE ROADMARYSVILLE, CA 95901Your application will not be considered until all the documents have been completed andreturned to our office.YOUR DEADLINE FOR RETURNING THIS APPLICATION:_______

Upward Bound Yuba College2088 N. Beale Road, TRiO/Cal-SOAP Office, Marysville, CA 95901 (530) 749-3858UPWARD BOUND STUDENT APPLICATIONYuba CollegeName________________First Name Last Name MiddleStreetAddress City Zip____________Home phone____________________________Cell PhoneMailing Address (if different)______________E-mail address ____________________________________Social Security #___________________________________City_____________________________ Zip____________Ethnicity Sex: Male FemaleSchool Counselor Grade___________BirthdatePlease fill in the spaces below for all the members of your household. (Include yourself)Name Relationship Age Grade* School________________________________________________________________________*or highest grade/year in school/college completed. Please attach another piece of paper if necessary.What languages are spoken in your home? ________________________________________________________________Have you or any of your siblings been enrolled in an Upward Bound Program? YesNoIf yes, who, and at what college/university?Are you or any of your siblings in another outreach program such as ETS, MESA, or AVID?Yes No If yes, who?Which program(s)?Do you have a job? Yes No If you have a job, where?PositionDays and times you work

Upward Bound Yuba College2088 N. Beale Road, TRiO/Cal-SOAP Office, Marysville, CA 95901 (530) 749-3858Please answer the following questions as honestly and specifically as possible. Attach another page if necessary.What do you think is the function of the UPWARD BOUND Program? _________________________________How do you expect the Upward Bound PROGRAM to help you? ______________________________________What do you feel you can contribute to UPWARD BOUND?_________________________________________What do you think will be expected of you as an UPWARD BOUND student? _____________________________________________________________________________________________________________________________________________________________________________________________________________________What school subjects are your strongest? Why?__________________________________________________________________________________________________________________________________________With which subjects do you have difficulties? Why? ___________________________________________________________________________________________________________________________________________Are you willing to meet with the Upward Bound Specialist at your school?Yes No Not sureAre you willing to participate in after-school tutorials at your school? Yes No Not sureAre you willing to participate in the Upward Bound Saturday Academies at your school?Yes No Not sureAre you willing to participate in the Upward Bound Saturday Enrichment Activities?Yes No Not sureAre you willing to participate in a 6-Week Summer Academic Program at Yuba College?Yes No Not sure

Upward Bound Yuba College2088 N. Beale Road, TRiO/Cal-SOAP Office, Marysville, CA 95901 (530) 749-3858UPWARD BOUND STUDENT APPLICATIONYuba CollegeName__________________Last Name First Name MiddleAUTOBIOGRAPHICAL ESSAY: Please write a brief autobiography. Include information about your familybackground, educational and career goals, and anything else that may be helpful in giving us a more complete pictureof you. You may use additional paper if necessary.This is to certify that all information provided is true and accurate to the best of my knowledge. Furthermore, I give UPWARD BOUND at YubaCollege my permission to receive copies of my educational records and other materials necessary for participation in the program. Furtherpermission is granted to request academic and financial aid information and records from any and all postsecondary institutions in order to trackcollege progress. I understand all of my records will be kept in confidence in accordance with the Privacy Act of 1974. If selected as a memberof the UPWARD BOUND Program at Yuba College, I agree to participate in the entire program and conduct myself in a way to bring credit tomy family, my community, my school, the UPWARD BOUND Program and myself. I will not use alcohol or other drugs and will abide by therules and regulations set forth in the UPWARD BOUND policy for the entire length of time that I am a member. I agree to attend plannedmeetings during the academic year and the summer program.____________________________________Student’s Signature_______________________________Date

Upward Bound Yuba College2088 N. Beale Road, TRiO/Cal-SOAP Office, Marysville, CA 95901 (530) 749-3858INSTRUCTIONS TO STUDENT: Please give this form to your school counselor, teacher, principalor church leader to complete for you.UPWARD BOUND STUDENT REFERRAL/RECOMMENDATION FORMStudent Name____________________________________________FirstLastGrade__________ School __________________________________Name of Person Providing Referral:_________________________________________ Student’s GPA ____________Title/Relationship: __________________________Phone: Work # _________________Home # _________________How do you know this student? _______________________________________________________________Please state frankly your evaluation of this student’s ability to benefit from the Upward Bound program.Keep in mind that the purpose of this program is to generate the academic skills and motivation essentialfor college success. Participants should possess the ability to pursue and achieve a four-year collegedegree, but may not be able to do so without the help of Upward Bound.Please address reasons(s) why you think the student has a need for the services of the program:To improve academically (identify specific subject areas of weakness): _____________________________________________________________________________________________________________________________________To improve motivational level: _____________________________________________________________________________________________________________________________________________________________________Social/personal problems (identify specific areas such as low self-esteem, interpersonal relationships, homeimprovement, etc.): ___________________________________________________________________________________________________________________________________________________________________________________________________Please provide any additional information or comments to help us better serve this student’s needs:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Referent’s Signature Return to Student or mail to: DateUpward Bound, Yuba College2088 N. Beale RoadMarysville, CA 95901(530) 749-3858 phone(530) 749-3817 fax

Upward Bound Yuba College2088 N. Beale Road, TRiO/Cal-SOAP Office, Marysville, CA 95901 (530) 749-3858UPWARD BOUND ELIGIBILITY FORMStudent Name____________________________________________FirstLastGrade__________ School __________________________________Please answer both the Student and Parent/Guardian sections COMPLETELY.Street Address ___________________________________________ CityZip_________________Mailing Address (if different)_______________________________City______________________ Zip_________________Home phone______________________ E-mail address _________________________Cell Phone______________________U.S. Citizen? Yes NoSocial Security #_______________________US Resident Yes No If yes, please provide a copy of your residency card .Ethnicity_________________________Sex: Male Female Counselor______________________________ GPA _____________Birthdate _____________Career Goal _____________________________________ Do you plan to go to college? Yes No WHERE? 2-year College 4-year College Vocational/Technical Military Not sure right nowPARENT INFORMATION: (To be completed on the parent or guardian of applicant)Name __________________________________________Relationship ________________________ Occupation ___________Name __________________________________________Relationship ________________________ Occupation ___________Number of family members living at home: Adults _________ Children ____________ Total _______________________**ALL INFORMATION WILL BE HELD IN STRICT CONFIDENCE**If you filed an income tax return, please provide taxableincome from the Prior Year. See Income Tax Forms asfollows: Line 27-1040A; Line 43-1040; or Line 6-1040 EZTaxable Income* ___________________________________Year of Return _____________________________________*To verify this information and meet the U.S. Department ofEducation Requirements, we must have a copy of yourmost recent Federal Tax Return.$ 0 - $16,335$16,336 - $22,065$22,066 - $27,795$27,796 - $33,525$33,526 - $39,255$39,256 - $44,985$44,986 - $50,715$50,716 - $56,445$56,446 - AboveIf you did not file an income tax return last year, please complete thefollowing information for the most recent year.**Wages $_______________ SSA/SSI $_________________VA/GI Bill $ ___________ Unemployment $____________Pension/Retirement _________________________________Food Stamps $ ____________________________________Other (specify) ____________________________________**To verify this information and meet the U.S. Department ofEducation requirements, we need a statement from a caseworkeror a copy of a document confirming this information.

Upward Bound Yuba College2088 N. Beale Road, TRiO/Cal-SOAP Office, Marysville, CA 95901 (530) 749-3858PARENT/GUARDIAN INFORMATION (Please fill out COMPLETELY):Mother/GuardianFather/GuardianName:Occupation:Highest grade level completed for each parent (please CIRCLE one for each parent):Grade School K - 5 K - 5Jr. High 6 -8 6 - 8High School 9 – 12 9 - 12Some College 1 2 3 4 5+ 1 2 3 4 5+Vocational Program Yes No Yes NoIs either parent a Graduate of a 4-year College or University with a Bachelor’s Degree? No Yes This is to certify that all information provided is true and accurate to the best of my knowledge. I herebygive my permission for the Upward Bound Program at Yuba College to have access to any school or agencyrecords of (student’s name)____________________________________________________________To determine eligibility for the program and to monitor the status and progress in secondary school. Furtherpermission is granted to request information and records from any and all postsecondary institutions in orderto track college progress. In addition, I give my permission for my child’s name, photograph, work and/orstatements to be kept in strict confidence and in accord with the Privacy Act of 1974.________________________________________ __________________________________ _______________________Parent/Guardian’s Signature Student’s Signature Date

Upward Bound Yuba College2088 N. Beale Road, TRiO/Cal-SOAP Office, Marysville, CA 95901 (530) 749-3858UPWARD BOUND YUBA COLLEGE STUDENT NEEDS ASSESSMENTThis survey contains a number of statements about student needs. Please give your honest opinion of how the UPWARD BOUND Program canmeet your needs. Your answers will be kept confidential.Academic NeedsStrongNeedSomeNeedNoNeed1. To learn how to complete and turn in my homework on time.1232. To get better grades in school.1233. To take tests better and with less anxiety1234. To organize my time, activities and responsibilities better.1235. To learn more about high school requirements for college.1236. To listen better in class and ask more questions.1237. To relate to and communicate better with my teachers.1238. To identify, set and evaluate goals for the future.123My academic goal is __________________________________________________________________________________Personal NeedsStrongNeedSomeNeedNoNeed1. To better understand my parents and other adults.1232. To learn to deal with conflict in a positive manner.1233. To be more accepting of my physical appearance.1234. To learn how my self-esteem affects my behavior.1235. To know how to get along better with the opposite sex.1236. To learn to accept people who are different from me.1237. To learn more about the use/abuse of drugs and alcohol.1238. To accept greater responsibility for my actions.123My personal goal is _________________________________________________________________________________Career and Postsecondary NeedsStrongNeedSomeNeedNoNeed1. To explore a variety of career opportunities.1232. To learn more about job applications, resumes, and interviews.1233. To learn more about the postsecondary admissions process.1234. To prepare for exams like the PSAT, ACT, or SAT.1235. To visit more colleges and technology centers.1236. To learn more about college costs and how to pay for college.123Name a college or university you would like to visit __________________________________________________