KCC Upward Bound Student Referral Form

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 & more. You are not expected to have knowledge of every item below. Please complete only the sections you feel comfortable answering based on your experience with the student. Your insight into the student’s likelihood to utilize the opportunities provided by UB is an important part of the application process. Thank you!
Your Name:*

First NameLast Name
Email Address:*
School:*
Name of Student:*

First NameLast Name
Student's Email Address or Student ID #:*
Is the Student an English Language Learner (ELL)?

YesNo
What grade is the student currently in?

8th (Students are eligible for UB participation during the summer in-between 8th and 9th grades)9th10th11th12th
Relationship to Student:*
What course is the student taking with you as their instructor?
What is the student's current non-weighted GPA?

3.5—4.03.0—3.42.5—2.92.0—2.41.9 or below
What is the student's current course grade?

A+AA-B+BB-C+CC-D+DD-F
Has the student completed standardized testing?

YesNo
Which standardized test has the student completed?

PSATSAT
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?
How would you rate the student's overall attendance?
Please select the services that you believe would be the most beneficial to the student by participating in the Upward Bound program?

TutoringSAT/ACT Exam PrepCollege/Scholarship ApplicationsCareer ExplorationCampus VisitsFAFSA Completion
Is there any additional information you would like to add about the student?
Signature*

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