Upward Bound      Upward Bound

Student Application Form

Student Contact Information
Name
Last
First
Middle
Address
Street
City
State
Zip

Cell Phone #: format is ###-###-#### (include dashes)
OR if no cell phone enter 000-000-0000


Do you qualify for Free & Reduced Lunch?
Yes    No    Unknown   


Student E-Mail  *1 is required*:


RETYPE E-Mail:


Personal E-Mail  *1 is required*:


RETYPE Personal E-Mail:





Gender:
Male    Female   


 

 

Birth Month

Birth Date

Select Your High School (current -or- next fall):

Grade During 2020-2021 School Year:

Race/Ethnicity (Check Yes or No for each)

Yes    No    Hispanic
Yes    No    American Indian/Alaskan Native
Yes    No    Asian
Yes    No    Black or African American
Yes    No    White
Yes    No    Native Hawaiian or Other Pacific Islander
Yes    No    Other
Other (please specify):   

After Checking Yes or No for each, Click Here then Tab-On

Please check all of the areas of need that you believe apply to you:
(There are no “wrong” answers.)

Low proficiency scores on state tests
Low high school GPA
At the beginning of 10th grade, had not successfully completed pre-algebra or algebra course
Low educational aspirations
Lack of opportunity, support, and/or guidance to take challenging college prep courses
Lack of career goals and/or need for accurate information on careers
Limited proficiency in English
Lack of confidence, self- esteem, and/or social skills
Predominately low income community
Rural isolation
Interest in careers in math and science
Other
          Other Need (specify):
          

After Checking all that apply, Click Here then Tab-On

Parent/Guardian 1 Information
Name
Last:
First:
Relationship to Student
Parent/Guardian E-Mail
Daytime Phone #
Cell Phone #
Has this parent/guardian earned a bachelor’s degree from
a 4-year college or university?    Yes    No   

 

Mailing address IF different than applicants:

**Replace "Same as applicant" with Street, City, State, Zip
Parent/Guardian 2 Information
Change first and last to "Not Applicable" if you live in a single parent/guradian household.
Name
Last:
First:
Relationship to Student
Parent/Guardian E-Mail
Daytime Phone #
Cell Phone #
Has this parent/guardian earned a bachelor’s degree from
a 4-year college or university?    Yes    No   

 

Mailing address IF different than applicants:

**Replace "Same as applicant" with Street, City, State, Zip

Please indicate your preference:

The UB program prefers that all application materials and subsequent
paperwork be submitted electronically
via the UB website or by e-mail.
If you prefer we will send the application and other paperwork via regular mail.

You will not be penalized for using paper copies of the forms versus electronic versions.

I prefer to have all paperwork mailed directly to me, using the address provided above.
I prefer to use electronic forms when available.

I understand that the only forms that cannot be filled out electronically
are the Eligibility Verification Form and the Certification and Release Form,

which must be printed, signed, and mailed.


Academic Reference: We will send an email to this reference requesting
they complete the necessary form (you should follow up with them).

Last:
First:
Email:
Parent/Guardian Reference: We will send an email to this Parent/Guardian requesting
they complete the necessary participation survey (you should follow up with them).

Last:
First:
Email:

Student Self-Assessment

For each statement rate yourself (be honest, rate yourself with the number that reflects who you are now as a student not what you want to be).
There are no wrong answers.

Commitment to learning – I am

For each statement use the following c scale:
ALWAYS (5), MOSTLY (4), FREQUENTLY (3), SOMETIMES (2), RARELY (1)
1. in class/school regularly (attendance is important to me) 5   4   3   2   1  
2. on time for school and ready for the day with books, homework, and class supplies 5   4   3   2   1  
3. one that enjoys going to school and learning new things 5   4   3   2   1  
4. active in class taking notes and asking/answering questions 5   4   3   2   1  
5. able to follow directions 5   4   3   2   1  
6. resourceful and look for extra resources to learn from and will ask for clarification if I am confused 5   4   3   2   1  
7. one that has trouble taking quizzes/tests (anxiety on exams) 5   4   3   2   1  
8. one that makes (and/or turns in) corrections to assignments or exams 5   4   3   2   1  
9. able to take responsibility for my learning and do not blame others when I do not understand 5   4   3   2   1  
10. one that does not procrastinate (does not put off homework until the last minute) 5   4   3   2   1  
11. one that takes on extra credit opportunities 5   4   3   2   1  
12. one that only reads what I need to for school (No reading for pleasure) 5   4   3   2   1  
13. one that would be described as having a strong work ethic 5   4   3   2   1  
14. confident in my academic skills/work and abilities 5   4   3   2   1  
15. makes up missed schoolwork without being reminded if/when I miss class/school 5   4   3   2   1  
16. will ask the teacher for help when I am having trouble with my school work 5   4   3   2   1  
17. one that believes in doing only enough to get a passing grade unless I really like the subject 5   4   3   2   1  
18. easily distracted by others in the class (or day dreams) 5   4   3   2   1  
19. one that learns better when able to learn using a hands-on approach 5   4   3   2   1  
20. one that becomes frustrated when challenged 5   4   3   2   1  
21. determined to complete assignments and projects and not just give up 5   4   3   2   1  
22. one that sees failures or setbacks as opportunities 5   4   3   2   1  
23. self-driven (a self-starter, a self-motivated person) 5   4   3   2   1  
24. competitive and want to achieve the best grade I can (not just ride the C) 5   4   3   2   1  
25. optimistic about my academic future (I am going to go to college) 5   4   3   2   1  

Responsibility – I am

For each statement use the following rating scale:
ALWAYS (5), MOSTLY (4), FREQUENTLY (3), SOMETIMES (2), RARELY (1)
1. one that turns in assignments on time and complete 5   4   3   2   1  
2. one that uses in class time to study (wisely uses time) 5   4   3   2   1  
3. one that will take on leading a group project so I do not get a bad grade 5   4   3   2   1  
4. one that schedules time to study (manages/plans time well) 5   4   3   2   1  
5. able to admit when I do not understand 5   4   3   2   1  

Flexibility – I am

For each statement use the following rating scale:
ALWAYS (5), MOSTLY (4), FREQUENTLY (3), SOMETIMES (2), RARELY (1)
1. able to adapt to different teaching/learning styles 5   4   3   2   1  
2. one that works well independently (with minimal direct supervision) 5   4   3   2   1  
3. one that works well in groups 5   4   3   2   1  
4. one that would be described as a good team player (both a leader and a worker) 5   4   3   2   1  
5. able to listen to others patiently and without judgement 5   4   3   2   1  
6. one that takes risks (academically/socially brave – I am not afraid to raise my hand) 5   4   3   2   1  
7. one that wants to know the hows and whys rather than just accepting everything without question 5   4   3   2   1  
8. one that prefers to use computer based material to learn 5   4   3   2   1  

Study/Academic Environment at Home –

For each statement use the following rating scale:
ALWAYS (5), MOSTLY (4), FREQUENTLY (3), SOMETIMES (2), RARELY (1)
1. I maintain a place to study at home that is kept neat and uncluttered 5   4   3   2   1  
2. I keep all of my work for each subject together and carefully arranged in order 5   4   3   2   1  
3. I get interrupted a lot and that disturbs my studying when I am studying at home 5   4   3   2   1  
4. I have trouble studying because I get tired, bored, sleepy, or overwhelmed 5   4   3   2   1  
5. I waste too much time talking/texting with others, watching TV, listening to music, hanging out
with friends, scrolling Facebook or other social media, etc., to do good on their schoolwork
5   4   3   2   1  
6. I have too many other things to do that cause me to get behind in my school work (working a job,
babysitting, sports, clubs, etc.)
5   4   3   2   1  
7. I try to do my assignments at school so I can reduce the amount of homework I need to complete at home 5   4   3   2   1  
8. I have problems outside of school—with other students or at home
—that cause me to neglect my school work
5   4   3   2   1  
9. I complete my homework assignments on time 5   4   3   2   1  
10. I am sort of hit-or-miss on studying daily depending on my mood 5   4   3   2   1  
11. I study an hour or more each day outside of school 5   4   3   2   1  
12. I keep assignments up to date by doing work regularly from day to day and on weekends 5   4   3   2   1  
13. I prefer to study alone rather than with others 5   4   3   2   1  
14. I will advocate for myself and others 5   4   3   2   1  
15. I take pride in my work (good is not good enough) 5   4   3   2   1  

Your Essay:

We would like to give you the opportunity to tell us more about yourself. Please provide us with
a well-written and detailed essay - use correct grammar and spelling. The use of the first person -
I, me, etc. - is acceptable. We use this essay to get a glimpse of who you are as a person, so use
your own voice and express yourself! Include the following:
  • Tell us why you want to participate in Upward Bound
  • Include your future educational plans and careers that interest you
  • Provide any additional information that may be relevant to our decision in choosing you as a participant
You can type your essay directly into the online form. --OR-- you can write it out ahead of time, by typing the essay in either Word or Google Drive, and then copy and paste it into the online form.

A 500 character minimum is Required to submit online!