University Of New Orleans-Jefferson-UB-Application Form

Upward Bound

University of New Orleans - TRiO Programs
2000 Lakeshore Drive, ED 166, New Orleans, LA 70148

For questions, please call 504.280.6569

I am applying for Upward Bound (Jefferson)

Academics*

	Yes	No
1. My GPA is below 2.5 on a 4.0 scale.
2. I need help in one or all core subjects.
3. I have limited English proficiency.
4. I want to know more about Dual Enrollment.
5. I want to enroll in AP or IB courses
6. I need to prepare for ACT testing.
7. I want to know about my career options.
8. I need to know more about high school graduation requirements.
9. I need to learn time management, study skills, and/or test taking strategies.
10. I am highly motivated about my education.
11. My ultimate goal is to achieve a college degree.

Please check the services you would like assistance with from the TRIO Program.*

Academic AdvisingCareer Development/AdvisingFinancial Aid/Financial Literacy AdvisingAbstract/Critical Thinking SkillsTutoringTransfer AdvisingStudy SkillsProfessional DevelopmentTime ManagementTeam BuildingStress ManagementTechnology EducationPersonal WellnessFamily Wellness PlanningDecision MakingCommunication SkillsCollege Awareness/SelectionTechnical Assistance with completing formsPreparing for ACT/SAT/EOC

Section 4: Essay
In at least 250 words, please tell us why you deserve to be a part of this program and how it will benefit you in achieving your goals.*

0/400

Section 5: Parent Application
Marital Status*

SingleDivorcedMarriedWidowLegal GuardianStudent is Emancipated
Mother's Name

First NameMiddle InitialLast Name
Mother's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother's Phone
(999)999-9999
Mother's Email
example@example.com
Has Mother received a 4-year degree from a college or university

YesNo
If yes, Name of University
Student lives with Mother*

YesNo
Father's Name

First NameMiddle InitialLast Name
Father's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Father's Phone
(999)999-9999
Father's Email
example@example.com
Has Father received a 4-year degree from a college or university

YesNo
If yes, Name of University
Student lives with Father*

YesNo
Guardian's Name (Other than Mother or Father)

First NameMiddle InitialLast Name
Guardian's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Guardian's Phone
(999)999-9999
Guardian's Email
example@example.com
What is Guardian's relationship to student

GrandparentAunt/UncleSister/BrotherLegal GuardianOther
Student lives with Guardian

YesNo
Emergency Contact's Name (Other than Mother or Father)*

First NameMiddle InitialLast Name
Emergency Contact's Phone*
(999)999-9999
Emergency Contact's Email*
example@example.com

Household Information

	Name	Age	Relationship to Applicant	Grade Level (if in school)	Indicate free or reduced lunch at school (if applicable)	Check if attending college	Check if employed
1
2
3
4
5

Student Authorization and Release
I certify that all the information on this form is true and complete to the best of my knowledge. I authorize the UNO TRiO Programs to obtain/review any demographic, academic, and financial information needed for the purposes of data collection, documentation, reporting, or measuring progress both at the time of entry and throughout participation in the program.

I am also aware that the personal information that is provided to the UNO TRiO Programs will be protected under the Family Education Rights Privacy Act of 1974.
Student Signature*

Clear
Date Student Signed*

MonthDayYear
mm-dd-yyyy
Parent/Guardian Signature*

Clear
Date Parent/Guardian Signed*

MonthDayYear
mm-dd-yyyy