1. STUDENT'S FULL LEGAL NAME (last/first/middle):
2. SCHOOL NAME:
3. ADDRESS
4. Applicant's current enrollment status
ENROLLED
NOT ENROLLED plans unknown
NOT ENROLLED, plans to return
GRADUATED from high school
5. Please Check Highest Grade applicant will have completed by June of this year.
8TH
9TH
10TH
OTHER (describe)
6. As of the current semester, the applicant has earned:
The expected number of credits
Fewer than the expected number of credits
7. MOST LIKELY DATE OF STUDENT'S GRADUATION FROM HIGH SCHOOL:
/
Month
/
Day
Year
Date
8. Does student have any post-secondary plans that you are aware of?
YES
NO
IF YES, PLEASE EXPLAIN (program/major/school/institution, etc.)
9. Please indicate probably school action on Upward Bound credit recommendations.
School does not usually grant credit for work done in outside education programs.
School will consider accepting Upward Bound experience for high school credit.
10. Applicant's Grade Point Average, this year:
Cumulative:
11. Applicant's current rank in class
upper 1/4
second 1/4
third 1/4
lowest 1/4
12. Educational Program (best description of present/last high school program)
General
Remedial
Business
Commercial
Voc/Tech
Undecided
College preparatory
Other
13. SCHOOL SUBJECTS OF PARTICULAR INTEREST TO APPLICANT:
14. Areas in which applicant has special needs:
Communication skills
Reading
Mathematics
Natural Science
Social Science
Study Skills
Self image improvement
Interpersonal/group relations
Cultural enrichment
Other
15. Is applicant a participant in school's current year free/reduced price meals program?
YES
NO
Don't know
16. BRIEFLY DISCUSS THIS STUDENT'S NEEDS & LIKELY CAPABILITIES IF THOSE NEEDS CAN BE MET:
17. NOTE STUDENT PARTICIPATION IN ANY SPECIAL PROGRAMS OR CLASSES (SLBP, LD, ED, EMR, PT, etc.)
18. OTHER INFORMATION THAT MIGHT HELP US SERVE THIS STUDENT OR THE SCHOOL BETTER:
SIGNATURE:
*
Your Name
First Name
Last Name
TITLE:
*
DATE:
/
Month
/
Day
Year
Date
Please attach a copy of the student's current quarter grades, past year transcripts and 8th grade standardized test scores
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