University Of New Orleans-Jefferson-UB-Referral Form

The University of New Orleans

TRiO Programs

Upward Bound (UB) Jefferson

Teacher/Counselor Referral Form

Please provide your assessment of the student you are recommending for admission to The University of New Orleans’ UB programs. Your assessment of the student's potential is a key element in the selection process.
Student's Name

First NameMiddle InitialLast Name
School
Grade
Expected Date of Graduation*

MonthDayYear
mm-dd-yyyy
Carnegie Units Earned
Overall GPA*
Please attach a copy of student's Transcript, IEP, 504, test scores (i.e. LEAP, EOC, ACT) with this referral form.

Browse Files

Cancelof

Please mark appropriate column for each characteristic listed below*

	Excellent	Average	Fair	Poor
Attitude toward school
Ability to maintain a 2.5 GPA or higher
Level of maturity/integrity
Initiative/willingness to learn new things
Motivation/desire to attend college
Ability to advocate for self
Positive Interaction with peers/adults

Academic Endorsements*

	Yes	No	Eligible	Comments
Advanced Placement Courses
Honors Courses
Dual-Enrollment
International Baccalaureate

Thank you for the time and effort you have taken to complete this form.
Teacher/Counselor Name*

First NameLast Name
Teacher/Counselor Email*
example@example.com
Teacher/Counselor Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
The University of New Orleans * TRiO Programs (Educational Talent Search/Upward Bound)
2000 Lakeshore Drive, Bicentennial Education Building — Room 166, New Orleans, LA 70148
Phone: 504-280-6569 Fax: 504-280-5568