Clatsop Community College-UB

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Upward Bound Program Application

Thank you for your interest in Upward Bound (UB). We will notify you by mail if the student is enrolled. UB offers services to help students explore college and career opportunities and enter the college of their choice. If accepted, you will participate in workshops, educational guidance, field trips, summer programs and other activities. The Clatsop Community College Upward Bound Program is 100% funded by U.S. Department of Education grant of $367,181.

Family Information
All fields marked with * are required and must be filled

We are required to obtain this information to process your application. All information is strictly confidential and is used only to determine eligibility for Upward Bound services.

First-Generation: a student is considered First-Generation if the natural or adoptive parent(s) who the student live with has a 4-year Bachelor degree from a university. Please note - if the parent does not live with the student, we do not have to consider their education and you do not have to list them. We do not have to count 2-year Associates degrees.
Student lives with (please check all that apply)

Both parentsMotherFatherStepparentGrandparent(s)Legal GuardianFoster parent(s)Other
Please complete the following information about each parent/guardian who currently lives with this student:
Mother/Guardian's Name*

First NameLast Name
Does the Mother or Adoptive Parent who lives with the student have a 4-year Bachelor degree from a university?*

YesNoDoes not live with the student
Relation to the student (for example: Mother, Father, Step-parent, Grandparent)*
Check if same address as student

Check here
If not, please write your address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email address
example@example.com
Employer
Work Phone
(999)999-9999
Cell Phone
(999)999-9999
Emergency Phone
(999)999-9999
Father/Guardian's Name

First NameMiddle NameLast Name
Does the Father or Adoptive Parent who lives with the student have a 4-year Bachelor degree from a university?*

YesNoDoes not live with the student
Relation to the student (for example: Mother, Father, Step-parent, Grandparent)
Check if same address as student

Check here
If not, please write your address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email address
example@example.com
Employer
Work Phone
(999)999-9999
Cell Phone
(999)999-9999
Emergency Phone
(999)999-9999
(Optional) Notes - if you want to provide us with any other information regarding the student's First-Generation status please add it here.

Please list the names of the student's brothers and sisters who live with you and are in school.

	Name	School	Grade
1
2
3
4
5
6
7
8
9
10

(Optional) Notes - if you want to provide us with any other information on siblings or household members.

Authorization & Medical Release
All fields marked with * are required and must be filled
1. All information in this application is true and accurate to the best of my knowledge.
2. I give my permission for my son/daughter to participate in all Upward Bound activities. (You will be notified of any travel activities and asked to give permission specifically for trips.)
3. I authorize Clatsop CC Upward Bound to obtain student records and documents as necessary, including grade reports, transcripts, test scores, financial aid awards, and college admission and enrollment verification. This information will be held in strict confidence and in compliance with all federal laws (FERPA) regarding confidential student information. Information collected by Upward Bound will be used for UB purposes only.
4. I authorize Upward Bound to release or obtain information from any agency or program providing supplemental services to my student.
5. I give my permission for my student’s name, photograph, work and/or statements to be used by Upward Bound for promotional, publicity, or instructional purposes.
6. I understand that to stay enrolled in Upward Bound my student is expected to be a good school citizen, make good academic effort, and fully participate in all Upward Bound activities, including an annual summer program.
7. I consent to my child using the Internet and other technology and accept responsibility for appropriate use thereof.
8. I understand that completion of this form does not guarantee acceptance in Upward Bound.
The U.S. Department of Education (USDE) requires all Upward Bound programs to track students’ progress through postsecondary education and to report this information to USDE. Upward Bound’s continued funding depends on reporting this information about UB students. We report to USDE only the student information that USDE requires.

I grant permission to the Upward Bound program and Clatsop Community College and its authorized representatives to furnish first aid to my son/daughter as needed, and to seek medical attention through the nearest medical facilities when students are on field trips and other authorized activities. This permission is conditioned on the understanding that in the event of serious illness or injury or the need for hospitalization and/or major surgery, UB staff will make all reasonable efforts to contact me. Failure in such efforts should not prevent UB from providing emergency treatment as may be necessary for the best interest of my child.
Parent Signature*

Clear
To sign, please click and hold using your mouse or use your finger
Date*

MonthDayYear
mm-dd-yyyy
Student Signature*

Clear
To sign, please click and hold using your mouse or use your finger
Date*

MonthDayYear
mm-dd-yyyy

Upward Bound - "At a Glance"
All fields marked with * are required and must be filled

"The achievement of your goal is assured the moment you commit yourself to it." --Mack R. Douglas

The Upward Bound Program:

Individual Meetings: All students attend individual meetings with their Upward Bound Advisor for academic advising, career counseling and college planning. Advisors will schedule regular meetings and assign a required number of meetings. Advisors are also available at each school two days per week for meetings at the student’s request.

Monthly Class Meetings: Students attend one class meeting per month for information specific to their grade. These meetings cover information about study skills; academic requirements for getting into college; preparing for college; how to overcome blemishes on the academic record; career exploration; college exploration; and more.

Tutoring: Based on their grades, Upward Bound students may be required to attend after-school tutoring sessions. Tutors are on hand to help with math and English. Tutoring in other subjects may be available by special arrangement.

Skill-Building Workshops: Monthly workshops held at Clatsop Community College (CCC) offer supplemental instruction in core subjects and school success skills. Attendance at all workshops is strongly encouraged, and may be required depending on students’ grades.

Summer Academy: The Summer Academy is a mandatory part of Upward Bound. It is six weeks long and takes place at CCC from 9:00 am – 3:00 pm, Monday – Thursday. Fridays are field trip days. Students participate in service learning-based projects and academic seminars. Students who have previously completed the Summer Academy may have other summer options in limited circumstances; see UB Handbook for details.

The Upward Bound Senior Bridge Program:

The purpose of Upward Bound is to help students get into college. To that end, the summer after a student completes his or her senior year, Upward Bound offers the Senior Bridge Program.

The Bridge Program: For students who have graduated and are transitioning to college, Upward Bound will pay tuition and fees for approved summer courses at Clatsop Community College. This is the equivalent of up to $1000 in scholarship money because it allows students to take classes that count toward their college degree free of charge.

Graduating seniors may also participate in UB college preparation including:

1. Academic Advising Session: This component helps students understand what to expect during the transition to college and includes tips for college success.

2. College Readiness Trips: Students will travel to the campus they will be attending in the fall to sign up for additional services; meet advisors; locate classes and residential facilities; etc.

Benefits of Upward Bound:

Students participating in Upward Bound receive significant benefits including the following:
- Opportunity to earn up to $370 per year for Upward Bound participation
- Free academic tutoring
- Laptop computer loan program for academic use
- Free field trips to colleges, cultural events and college fairs
- Free workshops to help prepare for the SAT and ACT
Working and Upward Bound:

Many working students participate in Upward Bound year-round. Working should not keep you from being in UB. Most employers are happy to support your opportunity to be in this program. Part of your commitment to Upward Bound is to talk to your employer ahead of time to make arrangements to work later in the day or on weekends during the summer sessions, or to attend field trips. Please discuss this with your parents and the Upward Bound Advisor if you have any concerns about working and UB.

Upward Bound Student & Parent Agreement
Can you commit to all parts of the program?*

YesNoUnsure
Please list any questions or state potential conflicts you may have.
Student signature:

Clear
Date

MonthDayYear
mm-dd-yyyy
Parent signature:

Clear
Date

MonthDayYear
mm-dd-yyyy