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* 1. Personal Information

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* 2. Birthdate

Date

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* 3. Gender

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* 4. Are you a citizen of the United States?

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* 5. If "No" Permanent Resident I.D. Number

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* 6. Emergency Contact

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* 7. Family Information

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* 8. Family Information

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* 9. Income Documentation Information

Please check the annual taxable income range appropriate for your family. (Note: this information is required by the federal government to ensure we are providing services within our guidelines. Line 10-Form 1040, Line 27-Form 1040A) You are required to provide a current copy of your annual tax form.

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* 10. Non-Taxable Income: If you (parent/guardian) received non-taxable income for the previous year, please check the source(s) below:

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* 11. Does the applicant live in a foster home or is s/he a ward of the court?

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* 12. Ethnicity: Check one

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* 13. Race: If not Latino, check all that apply:

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* 14. Education Information

High School

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* 15. Present Grade Level

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* 16. Student and Parent Contract

In order for us to serve you with a strong academic, cultural, and collegiate preparatory program, we must have a genuine commitment from you. Please review the following. I understand that during my participation in Upward Bound:
     1.  My goal will be to complete high school and pursue post-secondary education.
     2. I will maintain at least a 2.5 GPA in high school.
     3. I will attend all meetings and appointments arranged with my Upward Bound Advisory.
     4. I will participate in all required Upward Bound activities. 
     5. I will abide by all rules and regulations of Upward Bound and College of the Siskiyous.
     6. Poor attendance, Lack of participation, or inappropriate behavior will be a basis for dismissal from Upward Bound. 

In Addition to the application data given here, we will need to obtain information from other sources to sufficiently meet the academic needs of our students and the reporting requirements of the U.S. Department of education. We gather information from high schools, colleges, testing institutions, and other agencies or universities on behalf of our students and program. Your signature on this form authorizes Upward Bound to:
     1. Request a copy of your middle/high school and/or college transcript and test scores from your school and/or the district.
     2. Request a copy of your SAT and/or ACT test scores.
     3. Use your Social Security number to request a copy of your financial aid application, transcripts, college enrollment status, and awards from the federal and state funding agencies or post-secondary institutions on your behalf.
     4. Communicate with representatives from agencies or post-secondary institutions on your behalf.
I hereby authorize Upward Bound to contact and request information from, as well as to share information with, the above-mentioned parties. I give my child permission to participate in Upward Bound activities if accepted. Our signatures below indicate our commitment to the Upward Bound Student and Parent Contract.
To the best of my knowledge, all the information I have provided in this application is true. 

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* 17. I give permission for child to be interviewed, photographed or record by Upward Bound for use on radio, TV, computer, printed news media, or in program promotional materials and documentation. Please Check:

Statements of Confidentiality
The information you provide in this application is confidential according to the Family Rights and Privacy Act. The U.S. Department of education has the authority to gather the information requested in this application (20 USC 1231a). The only persons authorized to examine the contents of this application are the student, their parents, employees at the school attended, and authorized Upward Bound staff. 
Student Needs Assessment
This survey contains a number of statements about your student needs. Please give your honest opinion of how UPWARD BOUND can meet your needs. Your answers will be kept confidential.
Academic Needs:
Personal Needs:
Career and Postsecondary Needs:

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* 42. Educational Plan
Which of the following are you interested in? (Please check all that apply. If you are unsure, please write "undecided"):

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* 43. Community Colleges

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* 44. California State Universities: Northern California

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* 45. California State Universities: Central California

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* 46. California State Universities: Southern California

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* 47. Universities of California: Northern California

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* 48. Universities of California: Southern California

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* 49. Private Schools

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* 50. Out of State or Other Types of Colleges
(University of Oregon, University of Nevada Reno, etc.) Please list:

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* 51. Military:

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* 52. Vocational Schools:

Career Development
Please choose from the following careers. Put a Check in the space provided next to those you are most interested in at this time.

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* 53. Health Careers

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* 54. Computer Science

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* 55. Business

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* 56. Social Services

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* 57. Education

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* 58. Arts

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* 59. Please name the career that you wish to pursue here if it has not been listed above:

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* 60. What can Upward Bound do to help you learn more about your field of interest? (example: "I would like to take a class that better explains my career choice to me, etc.)

Short Answers
The following questions should be answered in short, well organized 2-5 complete sentences.

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* 61. What type of people do you think go to college?

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* 62. Are you this type of person?

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* 63. What would you really like to do after you graduate from high school?

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* 64. Does anyone encourage you to go to college? If so, who?

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* 65. What would stop you from attending college?

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* 66. Name one thing that you really like about yourself and explain. 

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