2022-23 Upward Bound New Student Application ENG

Upward Bound New Student Application 2022-23

LNESC National Headquarters | 1133 19th Street NW, Suite 1000, Washington, DC 2036
Thank you for showing interest in our college preparation program! To access our Spanish application, click here: https://form.jotform.com/212567258836163

Instructions:
- Please try to answer the following questions to the best of your ability
- If you cannot upload an application component, do not worry! Upward Bound staff will follow up after you submit your application and provide assitance
If you have any questions or would like additional information do not hesitate to contact us:

Director

Oswaldo Camarena

OCAMARENA@LNESC.ORG

(360) 521-0447
Funded by the U.S. Deparment 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).
Part I - Student Section
Date:

MonthDay Year
First Name
Middle Name
Last Name
Social Security Number: *

Are you a U.S. Citizen?

YesNo
Are you a permanent resident?

YesNo
Alien Registration Number (if permanent resident)
Please attach a copy of you social security number or Alien Registration Card for Verification.

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Personal Email Address:
High School Currently Attending:

Current Grade Level:

9th10th11th12th
Mailing Address:

Street

APT

City State / Province

Postal / Zip Code
Cell Phone:
Please enter a valid phone number.
Date of Birth:
Age:
Gender:

MaleFemaleOther

What grades do you usually get?
What college or university do you plan to attend? (if you aren't sure simply list undecided)
Are you currently in any of these programs? If not applicable, DON'T mark any of the options below.

Upward Bound/UBMSGear UpTalent Search
What type of degree do you plan to obtain? Feel free to check more than one!

High School DiplomaVocational or Technical School DegreeTwo Year/Associate Degree4 Year College DegreeMaster DegreeDoctoral Degree
List any extracurricular activities you are involved in:
Do you work during the school year or plan to work during the summer? How many hours?

Please indicate your T-shirt size
What is your primary mode of transportation to school?

Drive myselfParents drive meSchool busPublic transportationOther
If you marked Public Transportation, do you need assistance with fare with attending school commitments? (Skip if not applicable)
Can you swim? Be Honest.

YesNo
PLEASE ATTACH A COPY OF YOUR MOST RECENT REPORT CARD TO THIS APPLICATION. USE THE TOOL BELOW TO UPLOAD.

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Personal Essay

In a 250 or more-word essay discuss ONE of 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.

Please write your essay using the space below: If there is not enough space you may attach a separate sheet with you essay to the application (only if filling out physical copy) *

Part II - UB Parent Application

Must be completed by Parent/Guardian
Student's Name
Mother's or Parent 1 Name:
Mother's or Parent 1 Primary Contact Number:
Mother's or Parent 1 Employer:
Mother's or Parent 1 Work Number:
Has Mother/Parent 1 received a bachelor's degree from a US college or university?

YesNo
Father's Name:
Father's or Parent 2 Primary Contact Phone Number:
Father's or Parent 2 Email:
Father's or Parent 2 Work Number:
Has Father/Parent 2 received a bachelor's degree from a US college or university?

YesNo
I certify that the information provided on this form is true and complete to the rest of my knowledge.

Clear
Date signed above:

MonthDay Year
Date
Emergency Contact:

Please provide the name of an adult that can be contacted in case of an emergency situation involving your so child.
First Name:
Middle Name:
Last Name:
Relationship to Applicant:
Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Cell Phone:
Work Phone:

Part III - Parent Application (Continued)

Please refer to the table below to determine your income eligibility for the Upward Bound Program. Income is one of three areas of we use to determine eligibility.
Number of people living in your household? Including yourself.
What is your households 2021 TAXABLE income level? (IRS From 1040; Line 43; IRS 1040A; Line 27; IRS Form 1040EZ; Line 6)
Parent - I certify that the information provided on this form is true and complete to the best of my knowledge.

Clear
Date signed above:

MonthDay Year
Date
Student's Name:
Student's Social Security Number:
Please attach a SIGNED copy of your 2021 U.S. Income Tax Return in order to verify taxable income. (If you would like some help uploading, please contact program staff)

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Part IV - Parent Release - Must be initialed by parent/legal guardian

The information requested authorizes media release, school records release, and internet release. The form also requests medical information and and authorizes medical treatment in case of an 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 resources. 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 submitting.
Release of School Records
As the parent/or legal guardian of the student listed above, I grant the Upward Bound Project of LNESC permission to obtain copies of my child's grade reports, transcripts, and/or standardized test scores from the school to assist my son/daughter in in achieving his/her educational goals. I also grant the UB staff 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 blanks*
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.
Parent/Legal Guardian’s Initialsblanks*
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/Legal Guardian’s Initialsblanks*
Medical Information and Medical Consent
Is the student covered by any medical insurance?

YesNo
If yes, please complete the following:
1. Name of Insurance Company:
2. Insurance Policy Number:
3. Name of Physician:
4. Physician's Office Telephone:
Please list any medical conditions including allergies and physician prescribed medicine that the student is currently taking:
List Medications/Medical History/:
Allergies:
Allergic Reaction:

As the parent/guardian of the above named student, I hereby authorize LNESC Upward Bound to provide medical diagnostic/or authorize the medical and/or surgical treatment of my child as it 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 herby released from any and all claims and causes of action that may arise out if such diagnosis, treatment or surgery to the extent allowed by the law. Furthermore, LNESC does not assume any financial responsibility, but wishes to provide the best services possible in case of emergency.

Clear
Date signed:

MonthDay Year
Date
Parent/Legal Guardian's Name (Please print):

CONTACT INFORMATION

LNESC National Headquarters | 1133 19th Street NW, Suite 1000, Washington, DC 2036 (360)- 521-0447 | OCAMARENA@LNESC.ORG
Dear Parent/Guardian:

Your child has indicated an interest the Upward Bound Program. Upward Bound (UB) is a FREE college preparatory program for high school students funded by a grant from the Department of Education and sponsored locally by LULAC National Educational Service Centers, Inc. 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
Since March of 2020, LNESC Upward Bound has shifted high quality academic services via online and by phone. Please contact us if you have any questions regarding the application or need assistance completing it. We are here to help!

Sincerely,

Oswaldo Camarena Gonzalez

LNESC Upward Bound Project Director
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Upward Bound New Student Application 2022-23

Part I - Student Section

Part II - UB Parent Application

Emergency Contact:

Part III - Parent Application (Continued)

Part IV - Parent Release - Must be initialed by parent/legal guardian

Medical Information and Medical Consent

If yes, please complete the following:

Please list any medical conditions including allergies and physician prescribed medicine that the student is currently taking:

Part V -STUDENT SELF ASSESMENT (Must be filled out by the student)

Part VI - Upon submission of your application, a program coordinator will reach out to the student via email to schedule their student interview. Following an application submission, a link will be provided for the student to request 2 letters of recommendation from two separate school staff.

CONTACT INFORMATION