UPWARD BOUND APPLICATION FOR ENROLLMENT

2018-2019

Telephone:508-894-4398

Office Location: Brockton High School, Yellow Building, Science Department 

Brockton Upward BoundApplication Instructions and Checklist

Dear Student and Parents/Guardian:

We are pleased to learn that you are interested in joining Upward Bound. Please take a moment to review the instructions for completing the application.

Complete the student background/educational information with student signature at the bottom of page.

Student - complete the essay questions (can be typed or handwritten on another page).

Student - please identify areas that you feel you may or may not need assistance.

Parents complete the Parent/Guardian section of the application which includes:o Income Verification - Educational Background – Statement of Need

Student and Parent/Guardian complete the Consent Release and Record Release and Confidentiality information. Please sign and date.

Choose two teachers or one teacher and one counselor to complete the teacher recommendation form. One recommendation must be completed by a teacher who teaches a core subject (Math, English, Science).

You will also need to submit the following documents with your application:

Proof of Citizenship: Birth Certification OR Naturalization Certificate OR Alien Registration Card

Income Verification: Parents will need to submit a copy of most recent tax return 1040, 1040a, or 1040EZ (we don’t need the entire document, we just need the page that has the name and number of dependents and the line that has the taxable income. Its typically on the first two pages of the tax return), or a letter from the Massachusetts Department of Transitional Assistance.

Student ApplicationBIOGRAPHICAL/EDUCATIONAL INFORMATION

To be completed by the Student: Today’s Date: __________________

Name:_______________________________________________________________________________(First Name) (Middle Name) (Last Name)

Home Address:________________________________________________________________________ (Number) (Street) (Apt #)

_____________________________________________________________________________________ (City) (State) (Zip)

Cell Phone#: ______________________________ Home Phone#: ________________________Alternate Phone#:__________________________ Email address: ____________________________Date of Birth: ________________________________________

(Month) (Date) (Year)

Social Security#: _________________________________ Sex: __ Male __ Female Race/Ethnicity:(1)______American Indian/Native Alaska (5)______Hispanic or Latino(2)______Asian (6)______White(3)______Black or African American (7)______Native Hawaiian or Pacific Island(4)______More than one race reported

Are you a U.S. citizen? (1)_______ Yes (2) _______ NoIf you are not a U.S. citizen, what is your Alien Registration #: ______________________________

Which language, other than English, is spoken at home? ___________________________________Educational Information:Homeroom: ___________ Guidance Counselor: __________________What grade are you in now? ________ Student ID#: _______________________Are you enrolled in any other academic support programs? Y__ N__ If yes, please list ____________________________________________________________________

Did you pass 7th and 8th grade MCAS? ___ Yes ___ No What were your scores? English ____ Math ___

Have you passed 10th grade MCAS? ____Yes ___ NoWhat were your scores? English ____ Math ____

This signature certifies that all the information on my ASA Upward Bound Application is true and completed to the best of my knowledge.

Student Signature:_______________________________________

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Student ApplicationStudent Essay

Please answer these short answer questions. Feel free to use another piece of paper if you need more space.

1. Why do you want to join Upward Bound?a. ___________________________________________________________________________

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. Please describe yourself and some of your hobbies.a. ___________________________________________________________________________

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3. What other commitments do you have? Would you be able to come to the after school program that takes place from 2:00-3:30?

a. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

4. Please describe your biggest accomplishment to this point in your life. Why do you consider that your biggest accomplishment?

a. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

5. Please list and explain three goals you have for yourself.a. ___________________________________________________________________________

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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6. What is your favorite class and why? What is your best academic subject? What is your worst academic subject?

a. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

7. Please tell us whether your grades are a true reflection of your ability. Why or why not?a. ____________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

8. What do you want to do for a career?a. ____________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

9. Please check below the highest level of education you expect to complete and in a brief statement please explain your answer.

__ High School ____ Career or Vocational Degree _____ Certificate Program

___ 2 Year College _____ 4 Year College _____ Master’s Degree _____ Doctorate ____________________________________________________________________________________________________________________________________________________

10. Why should we choose you to join UB?a. ____________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Student ApplicationStatement of Need

This survey contains a number of statements about needs. Your answers will be helpful in determining the future service offered through the Upward Bound Program. Your cooperation in filling out this survey is appreciated. When filling out the survey, please give your honest opinion regardless of how others may respond to the statements. Completely fill out the survey. All answers are kept confidential. Thank you.

Directions: The following survey contains 32 statements about student needs. You are to indicate, using the Response Key below, whether or not you see the statement as a need of yours and how well the need is currently being met. Please take your time and consider the question on an individual basis.

RESPONSE KEY No need or Some Need High Need

Need being met1. I need to hand in my homework on a more

consistent basis. ___ ___ ___2. I need to get better grades in school. ___ ___ ___3. I need to learn how to take better notes. ___ ___ ___4. I need to develop stronger study habits. ___ ___ ___5. I need to learn test taking strategies ___ ___ ___6. I need to learn relaxation techniques to reduce

my test anxiety. ___ ___ ___7. I need to learn how to manage my time so that personal, academic and extra-curricular activities are balanced. ___ ___ ___8. I need to learn how to read a text book more effectively. ___ ___ ___9. I need to develop better attitudes towards learning. ___ ___ ___10. I need to be enrolled in more College Prep courses. ___ ___ ___11. I need to listen more effectively in class. ___ ___ ___12. I need to communicate more effectively with my teachers. ___ ___ ___13. I need to know more about possible careers. ___ ___ ___14. I need to know how to apply and interview for jobs. ___ ___ ___15. I need to talk to a career counselor about my career plans. ___ ___ ___16. I need to learn more about financial aid for college. ___ ___ ___17. I need to understand college’s admission requirements ___ ___ ___18. I need to understand the college application process. ___ ___ ___19. I need to know how to choose which college to attend. ___ ___ ___20. I would like to learn more about Black Colleges. ___ ___ ___21. I would like to experience more cultural activities ___ ___ ___22. I would like to become familiar with people of other cultures.___ ___ ___23. I need to talk to a counselor about personal concerns. ___ ___ ___24. I need to develop more confidence in myself. ___ ___ ___25. I need to accept and like myself better ___ ___ ___26. I need to be more accepting of my physical appearance. ___ ___ ___27. I need to be a better listener and respond better to others. ___ ___ ___28. I need to respect authority better ___ ___ ___29. I need to learn to become more tolerant with people whose views differ from mine. ___ ___ ___30. I need to set goals in my life. ___ ___ ___31. I need to learn more about the use/abuse of

alcohol and drugs. ___ ___ ___32. I need to accept greater responsibility for my actions. ___ ___ ___

Parent Application

To be completed by the parent(s): Today’s Date: _______________Income Verification:Upward Bound is a TRIO program funded by the US Department of Education and managed by ASA. As a federally funded program, we are required to document the annual family income of each of our participants. This information is protected under the Privacy and Confidential Act.

There are_______ persons living in my household.

To the best of my knowledge, my total household income is as follows:(CHOOSE ONE)Weekly: $___________ Bi-Weekly: $__________ Monthly: $___________ Yearly: $ ____________

Please check any of the following benefits or services which your family receives:___Free/Reduced Lunches ___Public Welfare (ADC) ___Low-Income Housing ___Foster Care

Describe any unusual financial or family circumstances: _____________________________________________________________________________________

I certify that all the information noted is correct to the best of my knowledge.

Parent/Guardian Signature: ___________________________________________

Parent Educational Background:Upward Bound is a TRIO program funded by the US Department of Education and managed by American Student Assistance. As a federally funded program, we are required to document the parent/guardian educational background of each of our participants.

If living in the same household as the student:Mother’s name (or female guardian): _________________________________________________________

(First Name) (Middle Initial) (Last Name)

Did you graduate from a 4-year college/university within the United States? _______Yes _______No

If Yes, Name of college/university:

__________________________________________________________________College/University City/State

If living in the same household as the student:Father’s name (or male guardian): ___________________________________________________________

(First Name) (Middle Initial) (Last Name)

Did you graduate from a 4-year college/university within the United States? _______Yes _______No

If Yes, Name of college/university:

__________________________________________________________________College/University City/State

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Release Statements:

Statement of Need:Please indicate the areas in which your child most needs assistance from the Brockton Upward Bound Program:___College Prep Curriculum ___Career Counseling/Testing ___Career Field Trips___Financial Aid ___College Campus Visits ___College Admissions___Personal Advising ___Tutoring in ____________ ___College Essay Writing___ACT/(P)SAT Test Preparation ___Study Skills ___Other:____________

Has your child previously participated in a TRIO Program? ____Yes _____ No Which one? __________________

Consent and Release

I will will not allow ASA to use images and/or pictures of my child participating in Upward Bound activities in future Upward Bound brochures, applications, and other marketing information.

Parent/Guardian Signature: __________________________________________ Date: ______________

Records Release and Confidentiality Statement

I authorize the release of school records from my son’s/daughter’s file that may be requested by the Upward Bound. I understand that the Department of Education funds the Brockton Upward Bound Program and will use these records to provide academic advisement for my son/daughter. I also understand that these records will be handled in a confidential manner and that they will be made available only to program staff and representatives from the federal and state departments of education. The authorization is limited to an official school transcript, standardized test scores, student history, attendance records from 8th – 12th grade, student grades and progress reports, information concerning disciplinary actions, and information concerning future postsecondary enrollment.

I understand that this information will be placed in my child’s Upward Bound file as part of his/her income and background documentation. This information is protected under the Privacy and Confidentiality Act. I certify that all the information I have provided is correct and accurate to the best of my knowledge.

Parent/Guardian Signature: _________________________________________ Date: ______________ Student Signature: ________________________________________________ Date: ______________

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TEACHER RECOMMENDATIONS

Upward Bound is a year-round program that motivates and prepares high school students from families who meet federal guidelines for low income and/or whose parent(s) did not receive a degree from a four-year college for post-secondary education. During the school year students receive academic tutoring, develop study and test-taking skills, and participate in cultural activities, and workshops on college, careers, and financial aid. In the summer, students live on a college campus during the week, take rigorous academic courses, and participate in recreational, educational, and cultural activities.

Your candid evaluation of this student will help in the selection process. Your input will also help ups develop an academic support plan that meets the individual needs of the student. If you feel that you cannot give an honest and comprehensive evaluation of the student, please give the form to student so that s/he may find another person who will be able to complete the form.

Student’s Name: ______________________ Your Name: _________________________

Position: ___________________________ Organization: __________________________

I have known this student for: ____ years ______ months

What are the first words that come to mind when you think of this student: ____________________________________________________________________________________________

Comments

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I recommend ______________________________to the Upward Bound Program(Student’s Name)

[ ] With reservation[ ] Somewhat[ ] Highly

Signature: _____________________________________ Date:_____________________

Continued on Following Page)

TEACHER RECOMMENDATIONSCircle the appropriate answer(s) for each category:

Sense of Responsibility

Always Usually Sometimes Rarely No Basis for Evaluation

Consideration of Others

Usually Thoughtful

Usually Considerate

Inconsiderate

Unkind No Basis for Evaluation

Social Interaction with Peers

Healthy Relationships

Some Problems

Frequent Problems

Relates Poorly

No Basis for Evaluation

Leadership Ability

Excellent Good Average Poor No Basis for Evaluation

Emotional Maturity

Very Mature Average Somewhat Mature

Not Very Mature

No Basis for Evaluation

Self-Confidence Healthy Self-Image

Needs Some Support

Seems Overly Confident

Poor Self-Image

No Basis for Evaluation

Self-Control Highly Developed

Good Fair Poorly Developed

No Basis for Evaluation

Interaction with Adults

Comfortable Uneasy Dependent Avoids Contact

No Basis for Evaluation

Creative, Original Thought

Excellent Good Average Poor No Basis for Evaluation

Motivation Excellent Good Average Poor No Basis for Evaluation

Independence, Initiative

Excellent Good Average Poor No Basis for Evaluation

Intellectual Ability

Excellent Good Average Poor No Basis for Evaluation

Potential for Growth

Excellent Good Average Poor No Basis for Evaluation

Academic Achievement

Excellent Good Average Poor No Basis for Evaluation

TEACHER RECOMMENDATIONS

Upward Bound is a year-round program that motivates and prepares high school students from families who meet federal guidelines for low income and/or whose parent(s) did not receive a degree from a four-year college for post-secondary education. During the school year students receive academic tutoring, develop study and test-taking skills, and participate in cultural activities, and workshops on college, careers, and financial aid. In the summer, students live on a college campus during the week, take rigorous academic courses, and participate in recreational, educational, and cultural activities.

Your candid evaluation of this student will help in the selection process. Your input will also help ups develop an academic support plan that meets the individual needs of the student. If you feel that you cannot give an honest and comprehensive evaluation of the student, please give the form to student so that s/he may find another person who will be able to complete the form.

Student’s Name: ______________________ Your Name: _________________________

Position: ___________________________ Organization: __________________________

I have known this student for: ____ years ______ months

What are the first words that come to mind when you think of this student: ____________________________________________________________________________________________

Comments

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I recommend ______________________________to the Upward Bound Program(Student’s Name)

[ ] With reservation[ ] Somewhat[ ] Highly

Signature: _____________________________________ Date:_____________________

TEACHER RECOMMENDATIONSCircle the appropriate answer(s) for each category:

Sense of Responsibility

Always Usually Sometimes Rarely No Basis for Evaluation

Consideration of Others

Usually Thoughtful

Usually Considerate

Inconsiderate

Unkind No Basis for Evaluation

Social Interaction with Peers

Healthy Relationships

Some Problems

Frequent Problems

Relates Poorly

No Basis for Evaluation

Leadership Ability

Excellent Good Average Poor No Basis for Evaluation

Emotional Maturity

Very Mature Average Somewhat Mature

Not Very Mature

No Basis for Evaluation

Self-Confidence Healthy Self-Image

Needs Some Support

Seems Overly Confident

Poor Self-Image

No Basis for Evaluation

Self-Control Highly Developed

Good Fair Poorly Developed

No Basis for Evaluation

Interaction with Adults

Comfortable Uneasy Dependent Avoids Contact

No Basis for Evaluation

Creative, Original Thought

Excellent Good Average Poor No Basis for Evaluation

Motivation Excellent Good Average Poor No Basis for Evaluation

Independence, Initiative

Excellent Good Average Poor No Basis for Evaluation

Intellectual Ability

Excellent Good Average Poor No Basis for Evaluation

Potential for Growth

Excellent Good Average Poor No Basis for Evaluation

Academic Achievement

Excellent Good Average Poor No Basis for Evaluation