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

Lone Star College-North Harris Upward Bound

To: Teachers and Counselors

From: Upward Bound Staff

Re: Upward Bound Program Referral

You are being asked to complete a referral for the student to be admitted into the UpwardBound program. The program’s goal is to assist first generation and/or low-income students’ entrance into and graduation from the college or university of their choice. We are looking for applicants that have a strong desire to pursue a higher education and are willing to commit the time and effort to fulfill this goal. Based upon the program criteria, participant selection will be determined through overall points accumulated. Your evaluation will be a part of the total points calculated. Please complete all areas of the evaluation form.

We appreciate you taking the time to complete this referral. Please return to student upon completion or turn in to the Upward Bound office.

Thank you,
Upward Bound Staff
www.lonestar.edu/upward-bound

Student's Name

First NameLast Name

PERFORMANCE FACTORS

Rows	1	2	3	4	5	6
QUALITY OF WORK (Accuracy, thoroughness, neatness)
QUANTITY OF WORK (Completes required amount of work)
CREATIVITY (Imagination, originality)
MOTIVATION (Desire to learn and to be successful)
ADJUSTABILITY (Security, stability, adaptability)
DEPENDABILITY (Follows instructions, attendance)
COOPERATIVENESS (Constructive attitude, initiative)
DISCIPLINE (Follows rules and regulations)
SOCIABILITY (Self esteem, peer relations)

In what academic areas does this student need improvement?

Please provide any additional information or comments to help us better serve this student’s needs.

Evaluator's Name

First NameLast Name

Signature

Contact Number

(999)999-9999

Email

example@example.com

Teacher or Counselor Referral