Upward Bound Registration Packet

• Completed Student Application for Admission
• Medical Information Form
• Guidance Counselor Recommendation (must be completed by the Student's Guidance Counselor)
• Current Transcripts
• Income Statement Completed and Signed
• Authorization for Release of Academic Records

Please complete your application as soon as possible. Review of applications will begin immediately.

• The purpose of the Upward Bound Program is to provide its students the skills necessary to complete high school and enter college or technical college upon graduating from high school. Students who apply for the program must plan to attend college, have academic potential, need assistance with college preparation and be willing to put forth the effort to excel academically.

• Section 1 - Student General Information

• This application must be completed by a student’s parent or guardian.
• Name of Person Completing Application:*
• Relationship to Applicant:*
• Student Name:*
  First Middle Last
• Birth Date:*
  MM slash DD slash YYYY
• Gender:*
• Student's Email
  Enter Email Confirm Email
• Address*
  Street Address City State / Province / Region ZIP / Postal Code
• Are you a U.S. Citizen?*
  • YES
  • NO
• Social Security Number:*
• Home Phone No:*
• Cell Phone No*
• Ethnicity: Hispanic/Latino:*
  • YES
  • NO
• Race:*
  • Black or African American
  • Asian
  • White
  • Native Hawaiian or Other Pacific Islander
  • American Indian/Alaskan Native
  Select one or more races from the five racial groups listed:
• School:*
• Grade*
• Mother’s Name*
• Mother's Email
  Enter Email Confirm Email
• Occupation:*
• Place of Employment*
• Work Phone #*
• Father’s Name:*
• Father's Email
  Enter Email Confirm Email
• Occupation:*
• Place of Employment:*
• Work Phone #:*
• Name & Phone Number of Nearest Relative:*
• Do you have a court appointed guardian?*
  • Yes
  • No
• If yes, please provide name and address (if different from above):*

Select the highest-grade level completed by natural or adoptive parent:

I understand the purpose of the Upward Bound Program. If accepted, I agree to participate in the program. I further agree to comply with any rules and regulations established by the Director and staff of the Upward Bound Program with the understanding that failure to comply could result in dismissal. I certify that the information submitted in this application is accurate to the best of my knowledge.