UPWARD BOUND

VANCOUVER, WASHINGTON UPWARD BOUND 2020 - 2021
UPWARD BOUND
New Student Application
541.745.9120 cell Office: 360-604-3720

360.521.0447 cell Office: 360-604-3746
Coordinator Fort Vancouver/Heritage Evergreen High School

541.745.9120 cell
Director Evergreen High School

360.521.0447 cell Office: 360 - 604- 3758
For information visit our Facebook Page or Email us at Vancouver.UB@lnesc.org
Funded by the U.S. Department of Education

Please note that all applications are accepted for review regardless of race, color, national origin, religion, gender, sexual orientation, or disability (U.S. Department of Education - GEPA Section 427
Upward Bound New Student Application 2020 -2021
Revised 9/11/2020
Upward Bound Program Application 2020 -2021
INSTRUCTIONS:
Print clearly in black or blue ink if being filled out by hand. Be sure to answer all questions. Remember your parent/guardian’s signature is required. Submit your complete application directly to Upward Bound Office located at Evergreen HS Campus Student Success Center if filled out by hand.

You may also mail or email your complete application to:
LNESC Upward Bound Evergreen High School Rm 440B 14300 NE 18th Street Vancouver, WA 98684
PART I - STUDENT APPLICANT INFORMATION
Date:

Month Day Year
Date
Last Name:
Middle:
First:
Email Address:
Social Security Number: Required for department of education reports
Emai Address:
Citizenship:
NO

Are you a U.S. Citizen? YES YES
If NO Are you a Permanent Resident?
Alien Registration Number
If you are printing and signing the application by hand please attach a copy of your social security number or Alien Registration Card for verification. You must be a U.S. Citizenor Permanent Residentin order to qualify for the LNESC Upward Bound Program. If you are submiting this form online a copy of your social will be requested in the future during the interview process.
High School Currently Attending:
Current Grade Level:
9th

9th: 10th 11th 12th
Mailing Address:
Address

Mailing Address

Street Address Line 2

City State

Zip
Student Phone Number:
Home Phone Number:
Date of Birth:

Month Day Year
Date
Age:
Gender:

Male
Gender:

Female Other
Ethnic Background:

African American or Black American Indian Arab Asian/Pacific Islander Hispanic/Latino White
Upward Bound New Student Application 2020 - 2021
Revised 9/11/2020
More than one race

More than one race Other
Who do you live with?

Mother & Father Father (only) Mother (only) Guardian
Name of Guardian if you do not live with your parents:
What language is spoken at home?

English Spanish
What are your favorite school subjects?
What grades do you usually get?
What college or university do you plan to attend
What do you plan on majoring in?
What kind of career or job would you like to have?
Check all programs that you are currently in

Upward Bound/UBMS Gear Up Talent Search none
What type of degree do you plan to obtain? You can check more than one.

High School Diploma Vocational or Technical School Degree Two Year/Associate Degree 4 Year College Degree Master’s Degree Doctoral Degree
List any extracurricular activities are you involved in:
Do you work during the school year or plan to work during the summer?

No Yes
If Yes, when and where?
How many hours a week?
Upward Bound New Student Application 2020 -2021
Revised 9/11/2020
Please indicate your t-shirt size:
T-shirt size

XS: S M L XL 2XL 3XL 4XL
Primary Form of Transportation

I drive Parents Drive Me public transport
If you marked Public Transportation, do you need assistance with fare when attending our events?

No Yes
Can you swim?

Yes No
Be honest! We need to know for safety reasons. This will not hurt your chances of being accepted into the UB program.

*PLEASE ATTACH A COPY OF YOUR MOST RECENT REPORT CARD TO THIS APPLICATION.
Personal Essay
The personal essay is an important part of the selection process. In a 250 or moreword essaydiscuss ONEof the

following topics: 1) Events and persons in your life that have influenced you in your educational and professional

aspirations; OR 2) Why you are applying to the Upward Bound Program, and what you believe you will achieve from the

experience, and the contributions you can make to the program; OR 3) Discuss your most impressive accomplishment and

how it has impacted you. Please attach additional pages if necessary.
Use this section for your essay
Revised 9/11/2020
PART III – UB Parent Application (Must Be Completed by Parent/Guardian):
Student's Name:
Parent 1 Name:
Parent 2 Name:
Parent 1 Primary Contact Phone Number:
Parent 2 Primary Contact Phone Number:
Parent 1 Email:
example@example.com
Parent 2 Email:
example@example.com
Does either parent have a 4 year college degree

YES No
from a US college or university?

Yes No
I certify that the information provided on this form is true and complete to the best of my knowledge.
Parent's Signature

Clear
Date

Month Day Year
Date
Emergency Contact:
Please provide the name of an adult who can be contacted in case of an emergency situation involving your child.
Last Name:
Middle:
First:
Email Address:
Relation to Applicant
Address:
Apt. No:
City:
Cell Phone:
Work Phone:
Landline:
Upward Bound New Student Application 2020 - 2021
Revised 9/11/2020
PART III – UB Parent Application (Continued)
Size of Family Unit
PART IV – PARENT RELEASE (Must be initialed and signed by a parent or guardian) Upward Bound New Student Application 2020 - 2021

Revised 9/11/2020
The information requested authorizes media release, school records release, and internet use release. The form also requests medical information and authorizes medical treatment in case of emergency. LNESC is able to provide these free services through a grant from the U.S. Department of Education under TRIO’s Upward Bound Program and other grant sources. The Federal Privacy Act and Family Rights and Privacy Act protect the personal information you give on this application. This application is confidential when completed. Please complete the entire form before returning it to a LNESC Upward Bound Coordinator or our office.
Media Publication Release Authorization
I hereby grant LNESC full and absolute permission and all rights to copyright, publish, display, and use for any legal purpose or all photographs, together with descriptive text or statements, in which I or my property or my child appear.
Release of School Records
As the parent and/or legal guardian of the student listed above, I grant the Upward Bound Project of LNESC permission to obtain copies of my child’s academic grade reports, transcripts, and/or standardized test scores from the school to assist my son/daughter in achieving his/her educational goals. I also grant the UB staff my permission to speak with teachers, counselors and other school administrators at my child’s school in order to obtain and exchange information as part of the services provided by the UB Project.
Parent/Legal Guardian's Initials:
Internet Use Release
I hereby grant permission for my child to access networked computer services such as Internet, World Wide Web and electronic mail for UB activities..
Parent/Lega Guardian's Initials:
Medical Information and Medical Consent
Is the student covered by any medical insurance?

No Yes
Name of Insurance Co.
Insurance Policy Number
Name of Physician:
Office Telephone:
Please list any medical conditions including allergies and physician prescribed medicine that the student is currently taking:
Medication History
Allergies
Allergic reaction
As the parent/guardian of the above named student, I hereby authorize LNESC Upward Bound provide medical diagnostic and/or authorize the medical and/or surgical treatment of my child as may be necessary or appropriate under the circumstances for treatment of any illness or injury of my child. LNESC and its employees, and officers will not be liable in any way for any consequences from said diagnostic, medical and/or surgical treatment and are hereby released from any and all claims and causes of action that may arise out of such diagnosis, treatment or surgery to the extent allowed by law. Furthermore, LNESC does not assume any financial or other responsibility, but wishes to provide the best services possible in case of emergency.
Parent's/Legal Guardian's Signature:

Clear
Date:

Month Day Year
Date
Parent's/Legal Guardian's Name (Please Print):
Part V – STUDENT SELF ASSESSMENT (Must be filled out by the student) 1. Please check your educational goals (more than one may be checked):
Upward Bound New Student Application 2020 - 2021
Revised 9/11/2020
Educational goal is to obtain what type of degree

High School Diploma GED Bachelor’s degree from a public college/university Vocational/Technical certificate Bachelor’s degree from a private college/university
. What kind of career would you like to pursue?
A.
B.
. Do you know what type of classes to take in high school in order to prepare for college?
Yes No
Have you taken a college entrance exam (SAT/ACT/PAST)? If yes, what Exams and what were your scores?
. What is your G.P.A. (4.0 Scale)?
. What is your current class ranking? (Leave blank if you do not know)
Are you enrolled in ESL classes?

Yes No
Are you enrolled in a Dual Enrollment or Dual Credit Program?

Yes No
Have you ever visited a college/university campus? If yes, please list colleges.
. List colleges/universities you are interested in attending:
. If you choose not to attend college, which of the following options do you plan to pursue?

Military Employment
. If you don’t want to go to college, check all the reasons that apply:

College is too expensive I won’t qualify for financial aid I don’t want to be in debt with college loans My parents and I can’t afford to pay tuition I’ll make more money if I get a job College classes will be too hard My parents don’t want me going to college Other:
What other academic counselingladvising/tutoring programs do you participate in?
For Office Use Only:
After meeting with and/or assessing this student’s application for LNESC’s Upward Bound Program, I believe this student would benefit from LNESC’s services. This student has displayed an interest in:
(ACT®/SAT®)

Guidance and Advising to complete high school Information on colleges/universities Guidance on appropriate high school courses to take Information on college entrance exams Guidance on high school to college transition Assistance with college admissions Career information Financial Aid/Scholarship assistance Academic Tutoring Assistance with re-entering into high school Participating in LNESC workshops and field trips Assistance with enrolling in a GED program
UB Staff Name (Please Print):
Signature:

Clear
Date:

Month Day Year
Date
LNESC Upward Bound Evergreen High School Rm. 440B 14300 NE 18th Street
Upward Bound New Student Application 2020 - 2021
Revised 9/11/2020
Vancouver, WA 98684 Phone: 360-604-3700 ext. 8931
PART VI – UB Parent Application (Must Be Completed by Parent/Guardian):
Dear Parent/Guardian: Your child has indicated an interest in one of our three Upward Bound (UB) Programs: LNESC UB, Ford Driving

Dreams UB, and SW WA Community Foundation UB. Upward Bound (UB) is a FREE college preparatory program for high school students funded by multiple grants and sponsored locally by LULAC National Educational Service

Center. UB is specifically designed to strengthen the academic skills of eligible high school students to excel academically and pursue postsecondary degrees after high school graduation. Year-round services provided by UB include: Tutoring services during the school year to strengthen academic skills and prepare student for success at the college level A 6-week summer instructional component that is designed to simulate a college-going experience that includes daily coursework in English, math and science as well as other related activities such as field trips and special events Academic advising from UB staff and individual assistance with the college admissions and financial aid application process during the academic school year Saturday Academies once a month to educate students on various college, career, and life skills concepts College field trips and tours In order to comply with federal regulations, all LNESC UB participants must meet the following criteria: Be a citizen of the U.S or permanent resident Indicate an interest in attending college Demonstrate academic need Qualify as low income and/or neither parent has graduated from college with a bachelor’s degree Commit to remain active in UB through high school graduation Please complete this portion of the application and return with your son/daughter’s Student Application to the address or email listed above. You may also return your completed application to your son/daughter’s school counselor. All completed applications will be reviewed and eligible applicants contacted within 14 days for a Student

Thank you for your interest in the Upward Bound Project. Please call us at Phone: 360-604-3700 ext. 8931 if you have any questions or need additional assistance. Sincerely,

Oswaldo Camarena, Director, LNESC Upward Bound
Upward Bound New Student Application 2019-2020
Revised 9/20/2019 15
Should be Empty:

VANCOUVER, WASHINGTON UPWARD BOUND 2020 - 2021

UPWARD BOUND

New Student Application

Coordinator Fort Vancouver/Heritage Evergreen High School

Director Evergreen High School

Upward Bound New Student Application 2020 -2021

INSTRUCTIONS:

PART I - STUDENT APPLICANT INFORMATION

Email Address:

Citizenship:

If NO Are you a Permanent Resident?

Current Grade Level:

Upward Bound New Student Application 2020 - 2021

Upward Bound New Student Application 2020 -2021

Personal Essay

PART III – UB Parent Application (Must Be Completed by Parent/Guardian):

Emergency Contact:

Email Address:

Upward Bound New Student Application 2020 - 2021

PART III – UB Parent Application (Continued)

Size of Family Unit

Media Publication Release Authorization

Release of School Records

Internet Use Release

Medical Information and Medical Consent

Upward Bound New Student Application 2020 - 2021

For Office Use Only:

Upward Bound New Student Application 2020 - 2021

PART VI – UB Parent Application (Must Be Completed by Parent/Guardian):

Upward Bound New Student Application 2019-2020