Baton Rouge Community College-UB-1-Application Form

BRCC UPWARD BOUND
201 Community College Drive
Baton Rouge, LA 70806
225.216.8089 • Fax 225.216.8136

Dear Applicant and Parents/Guardians

On behalf of the administration, faculty and staff, we would like to thank you for your interest in applying to the Upward Bound Program at Baton Rouge Community College. The goal of the program is to develop in its participants the academic skills and motivation necessary for successful completion of high school and college.

Potential candidates for Upward Bound must commit to preparing themselves for post-secondary education before being accepted into the program. In return, Upward Bound provides its participants with a wide range of free services — tutoring, counseling, classroom instruction, college and career guidance, aimed at improving their academic skills and their motivation and determination to pursue a post-secondary education.

Program eligible students will be selected from those who complete an application and will be invited for an interview. Please note that the completion of this application does not guarantee program admission. Completed applications of students who are not selected as program participants during any given recruitment period are maintained on a waitlist until an opening occurs.

If you have any questions, please call 225.216.8089.

THANK YOU FOR YOUR INTEREST!

Applicant Information
Date

MonthDayYear
mm-dd-yyyy
Name*

FirstMiddleLast
Age
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Apartment Name (if applicable)
Apartment No. (if applicable)
Social Security No.
999-99-9999
Date of Birth

MonthDayYear
mm-dd-yyyy
Sex

MaleFemale
Current Grade
High School
Parish
Name of Parent/Legal Guardian

First NameLast Name
Home Phone No.
(999)999-9999
Parent’s/Legal Guardian’s Work No.
(999)999-9999
Alternate Phone No. (cellular phone)
(999)999-9999
Student’s e-Mail Address*
example@example.com
Parent’s/Guardian’s e-Mail Address
example@example.com
Current Grade Point Average
Upload grades/report card/transcripts/rising freshman leap scores

Browse Files

Cancelof
Upload 2

Browse Files

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Upload 3

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Upload 4

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Are you in another pre-college program?

YesNo
If so, what is the name of the program?
How long have you been a participant?
Citizenship

U.S. CitizenPermanent ResidentEligible Non-Citizen
Country of Birth
Upload Social Security Card

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Cancelof
Please attach a copy of supporting documentation, i.e., resident alien card

Browse Files

Cancelof
Name of Emergency Contact 1.

First NameLast Name
Relationship
Phone No.
(999)999-9999
Name of Emergency Contact 2.

First NameLast Name
Relationship
Phone No.
(999)999-9999
Name of Emergency Contact 3.

First NameLast Name
Relationship
Phone No.
(999)999-9999

Section A. Family Information
ONLY PARENTS/LEGAL GUARDIANS SHOULD RESPOND TO SECTIONS A-D.
ALL INFORMATION WILL BE HELD IN THE STRICTEST CONFIDENCE

We are required by the United States Department of Education to obtain income information from all applications served by the Upward Bound TRIO Program.

To be completed by Parents/Legal Guardians ONLY.
Applicant lives with

Both ParentsFatherMotherOther
If adopted or in foster care, is this recognized through a court of law?

YesNo
In what state?
Written verification must be provided.

Browse Files

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Name of the head of the household

First NameLast Name
Relationship to applicant?
As head of the household, do you claim the applicant as a dependent on your tax form?

YesNo
If no, please explain

List all family members who live in the household, including the applicant.

	Name	Age	Relationship to Applicant	Grade Level	Receiving Free/Reduced Lunches at School?	Attending College?	Employed?
1
2
3
4
5
6

This section must be completed and signed by the applicant's parent/legal guardian.
Applicant's Name

First NameLast Name
Please check the response that applies to you

I am not a graduate of a four-year college/universityI am a graduate of a four-year college/universityMy spouse is not a graduate of a four-year college/universityMy spouse is a graduate of a four-year college/university
Signature of Parent/Legal Guardian

Clear
Date

MonthDayYear
mm-dd-yyyy
Signature of Parent’s Spouse/Legal Guardian

Clear
Date

MonthDayYear
mm-dd-yyyy
APPLICANTS WILL NOT BE CONSIDERED FOR ADMISSIONS UNTIL THIS FORM IS COMPLETED AND SUBMITTED.

Section C. Parental Involvement
One of the goals of the Upward Bound Programs is to encourage parents/legal guardians to support participation in the development of student’s academic progress. As an Upward Bound parent, you would be expected to attend meetings, workshops, and provide support to your child while in the program.
Please list the top two things that you want Upward Bound to do for your child, if he/she is chosen for admission to the program.

Section D. Certification
PLEASE READ THIS SECTION CAREFULLY AND THOROUGHLY BEFORE SIGNING.

The Federal Government through the Department of Education funds the Upward Bound Trio Program at the Baton Rouge Community College. Applicants are admitted regardless of race, color, national or ethnic origins, or physical challenges. Ther personal information that you provide to the Upward Bound TRIO Program is available upon request to the United States Department of Education, Baton Rouge Community College, and federal and state auditors. Each of these agencies has the authority to gather information on the Upward Bound TRIO Program. The Information that you submit therefore becomes the property of the Upward Bound TRIO Program and its affiliates. In accordance with the Privacy Act of 1974, agencies other than those authorized are prohibited access to the files and records of the Upward Bound TRIO Program. Applicants, parents, and legal guardians are reminded that the affiliates of the Upward Bound TRIO Program have the authority to verify the information herein. Misrepresentation of information is a serious offense and because of the involvement of federal funds, any misrepresentation may lead to fines/imprisonment.

My signature certifies that all information provided herein this application is true to the best of my knowledge. I further understand that admission of applicants granted to the Upward Bound TRIO Program on the basis of incorrect information or an omission of fact, which if known, would have caused ineligibility of my child, is invalid and subject to action by the appropriate authorities.

I understand that all records will be kept in the strictest confidence in accordance with the Privacy Act of 1974.
Name of Responsible Parent/Guardian

First NameLast Name
Signature of Responsible Parent/Guardian

Clear
Name of Applicant

First NameLast Name
Signature of Applicant

Clear

Student Needs Assessment
This survey contains a number of statements about student needs. Please give your honest opinion on how the Upward Bound Program can meet your needs. Your answers are kept confidential.

Academic Needs (Select the value that applies)

	Strong Need	Some Need	No Need
1. To learn how to complete and turn in my homework on time
2. To get better grades
3. To better organize my time, activities, and responsibilities
4. To learn more about high school requirements for college
5. To listen better in class and ask more questions
6. To take tests better and with less anxiety
7. To relate to and communicate better with my teachers
8. To identify, set, and evaluate goals for the future

My academic goal is

Academic Needs 2

	Strong Need	Some Need	No Need
1. To better understand my parents and other adults
2. To learn to deal with conflict in a positive manner
3. To be more accepting of my physical appearance
4. To learn how my self-esteem affects my behavior
5. To learn how to get along better with members of the opposite sex
6. To accept greater responsibility for my actions
7. To learn more about the use/abue of drugs/alcohol
8. To learn to accept people who are different from me

My personal goal is

Please fill out accordingly

	Strong Need	Some Need	No Need
1. To explore a variety of career opportunities
2. To learn more about job applications, résumés, and interviews
3. To learn more about post-secondary admission processes
4. To prepare for exams like the PSAT, ACT, or SAT
5. To visit more colleges
6. To learn about college costs and how to pay for college

Name a college that you would like to visit
Applicant's Name

First NameLast Name
Applicant's Signature

Clear
Date

MonthDayYear
mm-dd-yyyy

Application Checklist
To be considered for selection into the Upward Bound Program, the following must be submitted:
- Completed and signed Application
- Copy of Appliant’s transcript
- Copy of Applicant’s current grades and LEAP results
- Copy of Parent’s/Legal Guardian’s current 1040 Income Tax Return/Verification of Income
- Copy of Applicant’s Social Security Card
- Copy of State Standardized Examination Scores
All of the above items/forms must be attached to the application when it is notarized. Incomplete applications will not be considered.

The following documents will be completed after the applicant is notified of pending selection and before the applicant is officially admitted as a participant in the Upward Bound Program.
- Invitation Acceptance Form
- Participant Health Record and Authority to Render Medical Services Form
- Emergency Contact Form/Family Information Form
- Permission Form for fieldtrips and special activities
- Parent/Guardian Survey
- School Release Form of Records
- Student Agreement
- Request for Taxpayer Identification Number and Certification (participant ONLY)
- Course Enrollment Survey
- Activities Survey
- Summer Food Application (if selected during summer session)
- Others
Thank you for Applying for the Upward Bound Program!