First Name
Address
Apt #
City
Zip Code
State
Parent/Guardian Phone #
Student Phone #
Social Security #
Date of Birth
School of Attendance
Crenshaw
Dorsey
Fremont
Hawkins
Jefferson
Jordan
Los Angeles
Manual Arts
Santee
Washington Prep
West Adams
PERSONAL INFORMATION (CHECK ONE)
If "Other" was selected, please specify
STUDENT CITIZENSHIP/RESIDENCY
NOTE: You must be a US citizen or legal resident of the United States in order to participate in and receive services from Upward Bound. We cannot enroll a student if their Social Security Number is not provided. All information will remain strictly confidential.
Permanent Resident#
If not a Citizen, country of Citizenship
Parent/Guardian 1
Name
Relationship
If Parent/Guardian 1 received a Bachelor's Degree in another country, please specify the country
Parent/Guardian 2
Name
Relationship
If Parent/Guardian 2 received a Bachelor's Degree in another country, please specify the country
EMERGENCY CONTACT INFORMATION
Emergency Contact Name
Relationship to Student
Phone Number
Home Phone Number
Work Phone Number
OTHER INFORMATION ABOUT STUDENT
STUDENT POST-SECONDARY PLANS
What do you want to study as a college student (college major)?
What is your career goal?
STUDENT ASSESMENT
This survey contains a number of statements about student needs. Please give your honest opinion about how the Upward Bound Program can meet your needs. Please CHECK all that you need assistance with. Make sure to answer the last statement.
I want tutorial services to improve my class grades. I would like advice on time management, test taking strategies, and study skills. I need guidance on courses (A-G) required for college admissions. I need help choosing college and career options that best fit me. I need help completing college admission (UC, CSU, Private, and CC) and financial aid (FAFSA) application forms. I need information about and help preparing for college entrance exams (SAT/ACT). I need advice on financial aid (e.g. scholarship, Grants, FAFSA) and other resources to pay for college. My parents and I need more information about financial aid. I would like to learn about financial literacy: how to use credit cards, how to open a checking account, how to manage college expenses, etc. I need help in choosing a college major. I want information about math and science college degrees.
APPLICATION CERTIFICATION
Student Name
Date
Parent/Guardian Name
Date
INCOME VERIFICATION INFORMATION
Please answer Question 1 (Q1) or Question 2 (Q2) NOT BOTH
This portion must be completed by the student's parent or legal guardian.
1A. TAXABLE INCOME
1B. Total number of EXEMPTIONS CLAIMED *
Q2: If you or your family did not file an income tax return, please check the following:
2B. SOURCE OF INCOME— Please complete the income information for at least one line below.
Weekly
Monthly
Yearly
Monthly
Weekly
Weekly
Monthly
Yearly
Weekly
Monthly
Yearly
Weekly
Monthly
Yearly
Other Income, please specify
Weekly
Monthly
Yearly
ATTACHMENTS
IF YOU FILED YOUR TAXES YOU MUST ATTACH A SIGNED COPY OF PAGE 1 & 2 OF YOUR INCOME TAX RETURN (1040 or 1040 SR) IN ORDER TO VERIFY ELIGIBILITY FOR TRIO UPWARD BOUND PROGRAM
INCOME CERTIFICATION
STUDENT NAME
DATE
PARENT/GUARDIAN NAME
DATE
Parent/Guardian Signature
Clear
STUDENT AUTOBIOGRAPHY
We are interested in getting to know who you are. Please submit a neatly hand-written or typed autobiography (200 words minimum). Attach this with your application. Make sure to address the following
Introduce yourself (your family, background, educational, and career goals).
Reasons why you would like to join TRIO Upward Bound and what do you expect to gain by joining the program.
How will being a part of TRIO Upward Bound help you reach your personal and academic goals?
Anything else that may be helpful in giving us a more complete picture of you (participation in extracurricular
activities, community service, working, etc.).
PARENT/GUARDIAN CONTRACT
Please read carefully
If accepted to the University of Southern California TRIO Upward Bound Program, I, the parent/guardian, agree to:
Encourage my son/daughter/ward to successfully graduate from high school and pursue higher education.
Support the Upward Bound goals set for my son/daughter/ward.
Require my son/daughter/ward to attend all Upward Bound activities, that are identified to assist the participant in reaching their academic goals which may include tutoring, workshops, Saturday Academies, and more.
Require my son/daughter to attend the MANDATORY six-week summer academy program.
Attend and participate in Upward Bound event(s) that require my presence.
Understand that there is a zero-tolerance policy in regard to blatant or implied gang insignia, dress, hand signs,
harassment or threatening behavior and/or use, furnishment, selling of weapons, alcohol, and drugs.
Understand that if my son/daughter/ward does not meet the goals and expectations of the program or fully use the services provided, he or she may be dismissed from the programs.
Understand that if my son/daughter/ward does not adhere to University of Southern California, USC Upward
Bound, state and federal policies, laws and expectations, he or she may be dismissed from the program.
GUARDIAN NAME
DATE
Parent/Guardian Signature
Clear
Successfully graduate high school and enroll in a college of my choice the semester/quarter after high school.
Make every attempt to complete a post-secondary educational program.
Enroll in courses that are required for college admissions as well as achieve and maintain at least a 3.0 GPA
Apply for college and financial aid during my senior year.
Participate in USC Upward Bound through the completion of my high school education and/or Summer Bridge Program.
Actively participate in all USC Upward Bound activities, which includes tutoring, workshops, Saturday Academy, field trips, educational and cultural activities, etc.
Actively participate in the 6-week Summer Program while I am a part of the Upward Bound program.
Communicate with USC Upward Bound Staff about educational and/or personal goals and attend all appointments arranged by Upward Bound Staff.
Grant USC Upward Bound access to my college enrollment, retention, and completion information.
Grant Upward Bound access to my financial aid information from colleges and the federal government.
I will comply with all the rules and regulations of USC Upward Bound, and I am aware that my failure to comply
could result in dismissal from the program.
Understand that there is a zero-tolerance policy in regard to blatant or implied gang insignia, dress, hand signs,
harassing or threatening behavior, weapons, alcohol, and drugs.
Understand that if I do not meet the goals and expectations of the program or fully use the services outlined for
me, I may be dismissed from the program.
Understand that if I do not adhere to University of Southern California, USC Upward Bound, state and federal
policies, laws, and expectations, I may be dismissed from the program.
STUDENT NAME
DATE
Yes, I, No, I do not grant permission for my/my child’s image, likeness or recording to be used in any form, unless necessary for the administration of the program in which my child is participating.
STUDENT NAME
DATE
PARENT/GUARDIAN NAME
DATE
Parent/Guardian Signature
Clear
RECORD AUTHORIZATION
ACADEMIC RECORDS STATEMENT
The person(s) singing below give consent and authorize the University of Southern California Upward Bound
staff and representatives:
To have access to, and make and receive copies of my son’s/daughter’s/ward’s academic records such as report cards, school transcripts, State standardized test scores, disciplinary records, class schedule, and SAT/ACT or GED scores.
I/We understand that these records will be kept in strict confidence and will be used solely to:
a) assess need/eligibility for program services
b) monitor my son’s/daughter’s/ward’s academic progress c) evaluate the effectiveness of program activities and d) fulfill program reporting
I/We consent to the disclosure of any personally identifiable (e.g. Social Security, Birthdate, etc.) information as defined by FERPA or my education records to the USC Upward Bound staff for the purpose of confirmation of the student’s post-secondary enrollment status as reported on the National Clearinghouse Student Tracker.
This authorization will remain in effect for six years following high school graduation.
I/We authorize the release and exchange of student financial aid information from
colleges/universities and the federal government to the University of Southern California Upward
Bound.
I/We authorized the University of Southern California Upward Bound program to share and discuss
information with school personnel in support of my son’s/daughter’s/ward’s academic success.
STUDENT NAME
DATE
PARENT/GUARDIAN NAME
DATE
Parent/Guardian Signature
Clear
PARENTAL CONSENT
The undersigned parent(s) or legal guardian(s) of
PARENT NAME
DATE
PARENT PHONE NUMBER
PARENT EMAIL
Send
