Volunteers Of America-Boyle Height-UB-Application Form

Upward Bound
PROGRAM APPLICATION

Student Information
Student's Name:*

First NameMiddle NameLast NameSuffix
Gender*

MaleFemale
School:*
Grade:*

9th10th11th12th Grade
Date of Birth:*

MonthDayYear
mm-dd-yyyy
Social Security Number:*
999-99-9999

ADDRESS
E-mail Address:*
example@example.com
Student Cell:
(999)999-9999
Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please give your current mailing address for all correspondence if address is different from above.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Citizenship
Please Select*

U.S. CitizenPermanent ResidentOther Citizenship
Card #:
Visa Type:
Place of Birth*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Home Language
What language is spoken in the home?*

EnglishSpanishVietnameseOther

Family Information
A Parent, Guardian, Or Other Adult Legally Responsible For The Applicant Must Complete This Section.
Student Lives With:*

Both ParentsMother OnlyFather OnlyRelative GuardianFoster ParentDisplaced youth
Relationship to student:*

Parent/Guardian #1
Name*

First NameLast Name
Home Phone:*
(999)999-9999
Cellular Phone:*
(999)999-9999
Employer*
Work Phone:*
(999)999-9999
E-mail Address:*
example@example.com

Parent/Guardian #2
Name

First NameLast Name
Home Phone:
(999)999-9999
Cellular Phone:
(999)999-9999
Employer
Work Phone:
(999)999-9999
E-mail Address:
example@example.com

Household

Please give the name and relationship of all members of your household. Include additional household member on separate sheet if necessary*

	Last Name	First Name	Relationship to Student	Age
1
2
3
4
5
6

Parent/Guardian Education
-Select the highest level of education completed by the parent/guardian
Parent/Guardian #1*

Did not graduate from high schoolHigh school graduateCollege Graduate (bachelor's degree only)
Name of University
Type of degree
Location
Parent/Guardian #2

Did not graduate from high schoolHigh school graduateCollege Graduate (bachelor's degree only)
Name of University
Type of degree
Location

RELEASE OF SCHOOL RECORDS
Student Name:*

First NameMiddle NameLast NameSuffix
Date of Birth:*

MonthDayYear
mm-dd-yyyy
Social Security Number:*
999-99-9999
I authorize Volunteers of America of Greater Los Angeles, Upward Bound Program to have access to and obtain copies of school records for the above named applicant. Access to academic records may include, but are not limited to the following:

• Class Schedule
• Transcript
• Standardized Test Scores
• Individualized Educational Plan (IEP)
• Attendance Data
• Verification of Enrollment (Secondary and Post-Secondary)
• Degree Verification (Secondary and Post- Secondary)
• Any additional information needed by the Upward Bound Program to complete the Annual Performance Report

required by the U.S. Department of Education

• Any additional information deemed necessary by the Upward Bound Program needed to make decisions

regarding the applicant’s secondary and post-secondary education

For the purpose of program completion of the Annual Performance Report (APR), I authorize the release of school records from grade 6th through the completion of post-secondary education to Volunteers of America Los Angeles. This form is valid for 10 years from initial signature date.
SIGNATURE OF PARENT/GUARDIAN*

Clear
DATE*

MonthDayYear
mm-dd-yyyy
PRINTED NAME OF PARENT/GUARDIAN*

First NameLast Name
SIGNATURE OF STUDENT APPLICANT*

Clear
DATE*

MonthDayYear
mm-dd-yyyy
Please select in lieu of signature*

I authorize Volunteers of America Los Angeles, Upward Bound to release my information to agencies other than the U. S. Department of Education.I give the Volunteers of America Los Angeles, Upward Bound permission for my child’s name, photograph, work and/or statements to be used by Volunteers of America Upward Bound for promotional, publicity or instructional purposes.

Academic Information
Are you currently participating in a college preparatory program (i.e. Upward Bound, Talent Search, Project Grad etc.)?

YesNo
Name of the Program:
Location:
Do you have an Individualized Educational Plan (IEP)

Yes - please provide a copyNo
Individualized Educational Plan (IEP)

Cancelof

ESSAY
Answer ALL of the following questions in the space provided in essay format. What are your academic goals? What are your personal goals? What have you done to reach your goals? Who has helped you in reaching your goals? Why do you want to participate in the Upward Bound Program?
Parent Name:

First NameMiddle NameLast Name
Parent Signature:

Clear
Date:

MonthDayYear
mm-dd-yyyy