Dear Parent(s) or Guardian(s): Your student is being invited to apply and potentially be selected to participate in a nation-wide college preparatory program. I cordially invite you to read further and take advantage of this opportunity. Broward College Upward Bound is a prestigious and federally funded program designed to assist current high school students to graduate high school and pursue post-secondary education. Students may only be accepted into the Program at Deerfield Beach, McArthur, and South Broward high schools. Each year there will be a total of 60 participants in each school. Once in the Program, students remain a participant through high school graduation and up to six years after. Participants must maintain no less than a 2.5 grade point average and are expected to attend services. They will be able to earn a monthly stipend. Upward Bound provides tutoring services; SAT/ACT preparation; and motivational presentations and workshop on a variety of topics such as college financial planning, career and personality assessment, test taking and study skills, etc. Additionally, college and university tours, student leadership conferences and cultural events are scheduled throughout the year. During the summer, Upward Bound participants attend a summer program on a Broward College campus designed to prepare them for the next year of study in high school or their first year in college. While the Summer Program s focus is academic it involves a full range of social, cultural and recreational activities. All Upward Bound services are provided at no expense to participants. A completed application along with the following documents must be provided to the Upward Bound Program office prior to consideration for the program: 1. Completed UBP application signed by both the applicant and parent/guardian- original signatures required (no copy/fax.) 2. Evaluation Form submitted by school counselor 3. Evaluation form submitted by teacher. 4. Transcript/permanent worksheet with high school grades/fsa scores, attendance, & conduct. 5. Signed 1040/1040A/1040EZ Prior Year Income Tax Return (Pg. 1&2). If taxes not filed, submit income statement i.e., Social Security, TANF, food stamps, and complete income form. (W2/ pay stub NOT ACCEPTED.) 6. Attach your most current class schedule Return completed applications to: 1. TRIO Upward Bound staff at the high school or 2. Broward College- TRIO Upward Bound 3501 SW Davie Road Building 15/110, Davie, FL 3332 Sincerely, Broward College TRIO Upward Bound
Please answer ALL questions clearly and completely. I. STUDENT DEMOGRAPHIC/ACADEMIC INFORMATION- ALL FIELDS REQUIRED Student Name: Student ID #: Last Name First Name M.I. Mailing Address: High School: Street Address Apt. # High School you attend or will attend City State Zip Code Grade Level: 9th 10 th 11 th 12 th Home Cell Phone #: Phone #: School Counselor: Student E- mail: Do you receive free/reduced lunch? Yes No Date of Birth: / / Gender: Male Female Are you taking ESOL classes? Yes No MM DD YYYY (If yes, what is your first language?) Required: Are you Hispanic/Latino? Yes No Are you currently participating in: IKON Y Boss Upward Bound FAU 21 st Century EOC YMCA Black or African American Asian Race: American Indian or Alaskan Native White With whom do you live? (Check all that apply) (Check all Native Hawaiian or Other Pacific Islander Mother Father Other that apply) First and last name of personalization period teacher?: Citizen US Citizen Permanent Resident Other Name: Status Nationality if not US Citizen Will your student need transportation afterschool? Yes No Period and time of your personalization period: Do you have any health conditions that will hinder your performance in the program? No Yes Explain: _ EMERGENCY CONTACT INFORMATION Name: Relationship: Phone: Name: Relationship: Phone: HONORS, AWARDS, LEADERSHIP POSITIONS, VOLUNTEERING, ACTIVITIES (List all activities in which you participate.) DISCIPLINE Have you served detention, been suspended, or had other disciplinary issues in high school? Yes No (Specify) FOR OFFICE USE ONLY: Date App Received _ Date First Service LI FG UNDRS Unweighted GPA: Immigration Status: Exp Grad Yr: Academic Need:
II. BROWARD COLLEGE UPWARD BOUND PROGRAM APPLICATION PARENT/GUARDIAN INFORMATION (Answer all questions for each parent/guardian who gives support to student.) Upward Bound Program Application Parent Form Directions: Give this form to your parent/guardian to complete. Return the completed form with your completed Upward Bound Application to the Upward Bound staff. STUDENT INFORMATION Student s Name: Student s Social Security Number: - - Address: City: State: Zip: Student s Cell Phone Number: Student s Alternate Number: May we text you and your child pertinent information about Upward Bound events and deadlines? Yes No Is your child a US Citizen? Yes No If no, is he/she a permanent resident? Yes No If so, what is his/her Alien Number? PARENT/GUARDIAN INFORMATION What is the name of the parent(s)/guardian(s) with whom the student regular resides? Relationship to Student: Birth Parent(s) Step Parent(s) Foster Parent(s) Grandparent(s) Other: Home Phone: Cell Phone: Occupation: Employer: Work Phone: Email: Mother s Full Name: Mother s Highest Level of Education Completed: Some High School GED High School Diploma Certificate Associate s Degree Bachelor s Degree Master s Degree Doctorate Degree Post Doctorate Father s Full Name: Father s Highest Level of Education Completed: Some High School GED High School Diploma Certificate Associate s Degree Bachelor s Degree Master s Degree Doctorate Degree Post Doctorate ****Continued on Back****
INCOME INFORMATION How many people are in your family (Living in your house or away at college including yourself)? Please check the box of the forms of income that you currently receive each month: Work Income Social Security Income Unemployment Income Retirement Income Disability Income TANF Did your family file a Federal tax return last year? Yes No If Yes, what was your Household TAXABLE Income? $ (Found on IRS Forms: Form 1040-Line 43 on; Form 1040EZ-Line 6; Form 1040A-Line 27) If No, what was your approximate family income? $0 $1- $18,090 $18,091 - $24,360 $24,361 - $30,630 $30,631 - $36,900 $36,901 - $43,170 $43,171 - $49,440 $49,441 - $55,710 $55,711 - $61,980 Over $61,981 Checking this box indicates the amount above is an estimate. I understand it may need to be verified if the student desires to apply for financial aid. CERTIFICATION: We, parent and student, have completed this form truthfully and completely. We have provided accurate income and educational levels for all parents/guardians. If we provide false information, we will be ineligible for the UB Program. We allow the school permission to release academic information (transcripts, worksheets, FCAT reports, attendance, behavior, and report cards) to assess student progress. We will submit this information, and a SSN/Resident Alien Number, and other requested information/documents before being accepted into UBP. If selected, we will attend a parent/student interview in which the student will complete a timed personal statement. If admitted into UBP, we will follow all requirements, including attending Saturday/after school tutorials during the academic year and commuting to a six or eight-week summer program on Broward College s Campus. Guardian Signature X Date: RECORDS RELEASE I give my permission for Broward College Upward Bound personnel to obtain my academic records. Records to be obtained include the following: quarterly grade reports, class schedules, official transcripts, test scores, and any other related information necessary for my participation in the Upward Bound program. I understand this records release will take effect from the date on this form and up to ten years after my participation in the Broward College Upward Bound program. Student s Name (Please Print) Parent/Guardian s Name (Please Print) Student s Signature Parent/Guardian s Signature
III. PHOTOGRAPHIC CONSENT AND RELEASE FORM (Required to participate in the program) I hereby authorize BROWARD COLLEGE ( BC )/ Upward Bound ( UB ) and those acting pursuant to its authority to: (a) Record my likeness and voice on a video, audio, photographic, digital, electronic or any other device or medium; (b) Use my name in connection with these recordings; and (c) Use, reproduce, exhibit or distribute in any medium (including but not limited to, print publications, video tapes, CD-ROM, Internet, social media, or any other medium) these recordings for any purpose that BC/UB, and those acting pursuant to its authority, deem appropriate, including promotional or advertising efforts. I release BC/UB and those acting pursuant to its authority from liability for any violation of any personal or proprietary right I may have in connection with such use. I understand that all such recordings, in whatever medium, shall remain the property of BC/UB, and that I will not receive any compensation for the use of such recordings. I have read and fully understand the terms of this release. Name: Address: City: State: Zip: Email: Phone: Signature: Date: Parent/Guardian Signature (if under 18): Date:
IV. PERSONAL STATEMENT In 600 words, describe why you would be a great candidate for the Upward Bound Program. Describe your leadership skills, community/school involvement, educational/professional goals and how you plan on making a difference in your school and community as a whole:
V. SCHOOL COUNSELOR EVALUATION Student Name: School: Student Phone #: School Counselor Name: Counselor Phone #: Student s attendance record: Needs Improvement Fair Good Attendance Students Current Unweighted GPA: Student FSA Scores: Math: Reading: INSTRUCTIONS: Please complete this evaluation form. Academic Background Yes Yes No No Is the applicant enrolled in college preparatory curriculum? Does the applicant have any truancy issues? If so, please explain. Yes No Does the applicant have an Individualized Education Plan? If so, please explain. Yes No Does the applicant have disciplinary challenges/referrals at school? Please explain. Yes No Does the applicant possess the academic desire to continue education beyond high school? Recommendation for Participation Strongly recommended Recommended with reservation Do not recommend Please provide comments on strengths and limitations that you feel are pertinent to the student s performance in a college readiness program. Additional comments can be written on a separate sheet and attached. Counselor Signature: Date: When completed, please return the form directly to the Upward Bound Advisor or Coordinator at your school.
The Upward Bound Program is 100% funded by the US Department of Education. The grant award for 2017-2018 is $257,500. Services are free.
VI. TEACHER EVALUATION FORM Student Name: School: Student Phone# Teacher s Name: Title: INSTRUCTIONS: Please check the appropriate rating for the student using the scale below: Scale Ratings: Exceptional Average Poor Cannot Rate Attitude towards completing assigned tasks/study skills: Intellectual Ability/Analytical Thinking: Motivation/eagerness to learn: Ability to do college preparatory coursework: Influence/leadership ability: Maturity/respect for others: Responsibility/integrity: Conduct/emotional stability: Punctuality/ personal appearance: Please provide comments on strengths and limitations that you feel are pertinent for the student s performance in a college readiness program. Additional comments can be written on a separate sheet and attached. Teacher's Signature: Date: Phone & E-mail Address: When completed, please return the form directly to the Upward Bound Advisor or Coordinator at your school. The Upward Bound Program is 100% funded by the US Department of Education. The grant award for 2017-2018 is $257,500. Services are free.
The Upward Bound Program is 100% funded by the US Department of Education. The grant award for 2017-2018 is $257,500. Services are free.
Upward Bound Student Self Assessment TRiO U P W A R O B O U N 0 Al'vfE: Instructions: ----------------------- DATE: ---------- 16:cADEMIC SKILLS: To help Upv,mrd Bowid Staff develop a plan of services for you, we must know what you need. Please read through the following lists and indicate whether you feel you have a "high need", "some need", or "no need " for help or improvement in that area Hi gh Need Some Need NoNee4 t English and writing skills: Spelling... Grammar... Punctuation... Organizing your writing... Writing essays and reports... Verbal expression (speaking skills)... English as a second language... Reading skills: Improving vocabulary... Reading speed... Comprehension (understanding)... Retention (remembering what you read)... Math skills: Basic arithmetic... Basic Algebra... Advanced math... Science skills... Social Studies skills... Learning and study skills... Time management... Developing good study habits... Studying for and taking tests... Taking notes in class... Developing library skills... Careers: Setting educational goals...... --------- Exploring career options............ --------- Identifying career interests...... --------- Identifying career aptitudes... ---------- Personal motivation: Improving school/class attendance..... --------- Sudying/doing home\vork...... ---------- Improving attitude toward school... ---------- Setting goals and prioritie-s...... ---------- Personal counseling: Improving interpersonal skills... Building self-confidence... Working through a personal problem... --------- Working through a family problem... --------- Drng or alcohol use or abuse... College Admissions: Admission requirements... --------- Identifying and applying for scholarships Financial Aid... Deciding which college to attend... ---------- ---------- ---------- Are there other academic or personal areas in which you would like assistance or counseling? If yes, please explain:-------------------------------------