Student Referral Form
KCC Upward Bound (UB) aims to enroll and support students who demonstrate both potential for college success and the need for project services, including college exposure, tutoring, exam preparation, financial literacy education, and more. Your assessment of this student's likelihood to utilize the opportunities provided by UB is an important part of the application process. Thank you!
Your Name:
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First Name
Last Name
Email Address:
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School:
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Please Select
Kankakee High School
St. Anne Community High School
Kankakee Junior High School
Name of Student:
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First Name
Last Name
Student's Email Address or Student ID #:
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Is the Student an English Language Learner (ELL)?
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Yes
No
What grade is the student currently in?
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8th (Students are eligilble for UB participation during the summer in-between 8th and 9th grades)
9th
10th
11th
12th
Relationship to Student:
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Please Select
Teacher
Counselor
Administrative Staff
Other
What course is the student taking with you as their instructor?
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What is the student's current non-weighted GPA?
3.5—4.0
3.0—3.4
2.5—2.9
2.0—2.4
1.9 or below
What is the student's current course grade?
A+
A
A-
B+
B
B-
C+
C
C-
D+
D
D-
F
Has the student completed standardized testing?
Yes
No
Which standardized test has the student completed?
PSAT
SAT
What is the student's Evidence-Based Reading & Writing (EBRW) score:
What is the student's Math score:
How would you rate the student's overall class participation?
1
2
3
4
5
How would you rate the student's overall attendance?
1
2
3
4
5
Please select the services that you believe would be the most beneficial to the student by participating in the Upward Bound program?
Tutoring
SAT/ACT Exam Prep
College/Scholarship Applications
Career Exploration
Campus Visits
FAFSA Completion
Is there any additional information you would like to add about the student?
Signature
*
Submit
Submit
Should be Empty: