THE UPWARD BOUND TRIO PROGRAMS

THE UPWARD BOUND TRIO PROGRAMS

NEW STUDENT AND PARENT APPLICATION
Thank you for your interest in the Southern University Upward Bound TRIO Programs. Please read all enclosed material for program overview and applicant qualifications.
I am applying to
Applicant Name
Mailing Address
Address (City/State/Zip Code)
Applicant email address
Applicant cell phone number
Date of Birth

MonthDayYear
Date
Target High School Attending
Current Grade
Current Grade Point Average
Parent/Guardian name
Parent/Guardian Contact number
Parent/Guardian Email
Citizenship: (Please Select One)
Country of Birth
MaleFemale
Hispanic or LatinaNon-Hispanic or Non-Latino
WhiteAsianAmerican Indian / Alaskan NativeBlack or African AmericanNative Hawaiian or Other Pacific IslanderOther
What language is predominately spoken at your house?
What is your current letter grade in Math?
What is your current letter grade in Science?
What is your current letter grade in English?
I am highly motivated about my education.I need help in one or more core subjects.I have limited English proficiency.I need to prepare for ACT testing.I need to be enrolled in more college prep courses.I need to know more about high school graduation requirements.I need to learn more about time management, study skills, and/or test-taking strategies.
YesNo
Please list diagnosed learning disability, if applicable.
YesNo
YesNo
PERSONAL
I need to experience more cultural activities.I need to develop confidence in myself.I need to set goals in my life.I need to know how to assess and evaluate goals.I need to learn how to make decisions.I need to learn how to apply to college.I need to learn more about FAFSA and/or Financial Aid programs for college.I need to speak to someone about career planning.
Professional DevelopmentTeam BuildingStress ManagementTechnology EducationPersonal WellnessFamily Wellness PlanningDrug/Alcohol EducationDecision MakingCommunication Skills
YesNo
YesNo
If yes, where?
What do you like about school?
How much time do you spend doing homework each night?
YesNo
How many days have you been absent from school during the present school year?
YesNo
High MotivationAverage MotivationLow Motivation
What is your intended college major? Why?
YesNo
YesNo
YesNo
YesNo
List all of your extra-curricular activities. Please include school, church, community, and personal.
PARENT/GUARDIAN AND FAMILY ASSESSMENT & SURVEY
Both ParentsMotherFatherGuardianOther (please specify)
1.List the highest level of education attained by the applicant’s mother? for example, high school
2.List the highest level of education attained by the applicant’s father? for example, high school
3.List the highest level of education attained by the applicant’s legal guardian? for example, high school
I have discussed participating int he Upward Bound Program with my child.I have discussed attending and graduating from a college/university with my child.I review my child's grades with him/her after each grading period.I help my child plan his/her class schedule.I have met my child's teachers at school.I know the high school graduation requirements.I understand that a completed FAFSA is required for high school graduation.I am aware of TOPS.I have established rules for studying in my home.
13.How do you feel about helping your child with homework?
Income Verification
I (Parent/Legal Guardian), certify that my income for the previous year was
This includes monies received from Earned Wages, Unemployment, Child Support, etc.
The number of dependents living in my household during the previous year was
Release of Records Statement
With my signature (Parent/Legal Guardian), I hereby grant permission to the staff of the Southern University Upward Bound TRIO Programs to access my child’s school records (grades, test scores, attendance records, class progress, free or reduced lunch eligibility, and disciplinary records) from the time he/she is admitted into the Southern University Upward Bound TRIO Programs until the time he/she graduates from high school. Furthermore, I grant permission to the staff of the Southern University Upward Bound TRIO Programs to meet with my child for counseling conferences held at his/her high school during school hours.

Secondly, I hereby authorize post-secondary institutions to release to the Southern University Upward Bound TRIO Programs copies of academic records, enrollment data, and student aid awards at any college or university my child attends or will be attending until they graduate from college.
PLEASE READ THIS SECTION CAREFULLY
The Federal Government, through the Department of Education, funds the Southern University Upward Bound TRIO Programs. Applicants are admitted regardless of race, color, national or ethnic origin, or physical challenges. The personal information that you provide to the Southern University Upward Bound TRIO Programs is available upon request to the United States Department of Education, Southern University and A & M College, and federal and state auditors. Each of these agencies has the authority to gather information on the Southern University Upward Bound TRIO Programs. The information you submit therefore becomes the property of the Southern University Upward Bound TRIO Programs and its affiliates. In accordance with the Privacy ACT of 1974, agencies other than those authorized are prohibited access to the files and records of the Southern University Upward Bound TRIO Programs.

Applicants, parents and legal guardians are reminded that affiliates of the Southern University Upward Bound TRIO Programs have the authority to verify the information reported herein. Misrepresentation of information is a severe offense, and because of the involvement of federal funds, any distortion may lead to fines or imprisonment. All participant records will be kept in the strictest confidence per the Privacy Act of 1974.
Applicant Signature
Signature of Parent(s) or Guardian(s)
The Southern University and A & M College Federally Funded Upward Bound TRIO Programs are authorized to Serve Participants at an Annual Budgeted Amount of $263,937.00 for the Classic Upward Bound Program and $263, 938.00 for the Upward Bound Math and Science Programs. (2/1/18)
Date

MonthDayYear
Date
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THE UPWARD BOUND TRIO PROGRAMS

PERSONAL

PARENT/GUARDIAN AND FAMILY ASSESSMENT & SURVEY

Income Verification

Release of Records Statement

PLEASE READ THIS SECTION CAREFULLY