Lone Star College-North Harris-MANI-UB-Application Form

STUDENT APPLICATION

For more information, please visit our website at www.lonestar.edu/upward-bound
Application Packets Must Include:

1. Completed Application
2. A copy of your U.S. birth certificate and government issued photo ID
or
U.S. Passport, Certificate of Naturalization, Permanent Resident Card, or evidence from the Immigration and Naturalization Service of your intent to become a permanent resident
3. Completed Teacher/Counselor Referral Forms – 3
4. A signed copy of your parent/guardian’s signed most recent income tax return or a signed “Income Verification Form

Lone Star College-North Harris Upward Bound is a 100% federally funded program under the U.S. Department of Education.
- APPLICANT INFORMATION
- Name
  
  First NameLast Name
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Home Phone
  (999)999-9999
- Cell Phone
  (999)999-9999
- E-mail Address
  example@example.com
- Social Security Number
  999-99-9999
- Name of High School
- Grade
- Gender
- Age
- Date of Birth
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearmm-dd-yyyy
- Student ID #
- ETHNIC BACKGROUND
  
  Other
- CITIZENSHIP STATUS
  
  Other
- Permanent Resident Number
- HIGH SCHOOL COURSES (check all that apply)
- SCHOOL ACTIVITIES
- Organizations
- Sports
- Are you a participant of Educational Talent Search/TRIO?
- EMPLOYMENT
- Hours Per Week
- CAREER ASPIRATIONS: What career or type of career are you interested in?
- ACADEMIC ASPIRATIONS
- ACADEMIC/NON-ACADEMIC NEEDS AREAS: (Check all areas in which you need help.)
- To be completed by the parent or guardian of applicant:
- FATHER OR MALE GUARDIAN
- Relationship to applicant
- Name
  
  First NameLast Name
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Cell Phone
  (999)999-9999
- Work Phone
  (999)999-9999
- E-mail
  example@example.com
- Employer
- Occupation
- Highest grade completed
- Check all that apply:
- MOTHER OR FEMALE GUARDIAN
- Relationship to applicant
- Name
  
  First NameLast Name
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Cell Phone
  (999)999-9999
- Work Phone
  (999)999-9999
- E-mail
  example@example.com
- Employer
- Occupation
- Highest grade completed
- Check all that apply:
- FAMILY INFORMATION
- Who does the applicant currently live with?
- Primary language spoken at home?
- Does home have access to a computer?
- Does home have access to the Internet?
- How many people live in the household?
- Adults
- Children
- Does the family qualify for free/reduced lunch?
- Does the family qualify for Temporary Assistance for Needy Families?
- Does the family receive any of the following?
- PLEASE ATTACH A COPY OF YOUR SIGNED MOST RECENT INCOME TAX RETURN OR A SIGNED “INCOME VERIFICATION FORM”
  
  Browse Files
  
  Cancelof
- I certify that the above information is correct. I understand all information obtained will remain confidential. This information will be used to verify eligibility and to provide statistical data in compliance with federal and state regulations. I also give my consent to allow the LSC-North Harris Upward Bound Program to obtain transcripts and any educational records that pertain to my child’s academic progress.
- Parent/Guardian Signature
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearmm-dd-yyyy
- STUDENT ESSAYS
- Essay # 1: Please write a brief description of yourself, your interests and/or your values.
- Essay #2: Please write a paragraph describing why you want to participate in the Upward Bound Program and what you hope to gain from the program.
- List three personal or academic strengths:
- List three personal or academic areas in which you would like to improve:
- How did you hear about Upward Bound?

STUDENT APPLICATION