Community Teen Coalition, Inc.-Banneker H.S.-UB-Application Form

Dear Upward Bound Applicant:

We appreciate your interest in becoming a member of the Community Teen Coalition Upward Bound Program. If accepted, we are certain that you will find that our program will become a vital part of your high school years.

During the academic year phase, students are required to attend after school tutoring at Banneker and/ or Griffin High School for a minimum of 2 hours per week. Academic courses are offered during the summer program, which meets from 8:30 a.m. until 4 p.m. for six weeks, beginning late May/early June and ending mid July. Throughout the year, in addition to tutoring and academic courses, we offer SAT/ACT preparation, counseling sessions, recreational activities, field trips, college tours and cultural events. Some Saturday sessions are required.

Upward Bound is free to all participants. Meals and transportation are provided during the summer program, and students receive a small stipend year round.

In order for your to be considered for enrollment into the Upward Bound Program, a great deal of information must be obtained from you and your parents. Let me assure you that ALL information is protected by the Privacy Act and no one may see it unless they work with or for the Community Teen Coalition Upward Bound Program.

Once your application has been reviewed by the project staff, you will be notified. If you meet all qualifications, you and your parent(s) or guardian(s) will be scheduled for a personal interview with Upward Bound Staff.

If you have any questions, please do not hesitate to contact our office at (678) 994-5694.

Feel free to visit our website https://communityteencoalition.org and follow us on instagram @CommunityTeenCoalition for program updates and information.

Sincerely,

Community Teen Coalition

TRIO Programs
Community Teen Coalition

Upward Bound Program

Participant Application

CTC PARENT/GUARDIAN HOUSEHOLD INCOME FORM
The CTC Upward Bound Program is supported by a federal grant funding from the U.S. Department of Education; therefore, household income information is required.

Also, please indicate the income category below that reflects your household income:
SIZE OF FAMILY UNIT*
INCOME LEVEL CATEGORY*
For family units with more than eight members, add the following amount for each additional family member: $6,810.

All information obtained by CTC will be kept confidential.

Your signature below indicates to the best of your knowledge that the information provided on this form is true, complete, and accurate. Upon request, I agree to provide proof of family income. I also authorize CTC, Inc. Upward Bound staff to obtain copies of my child's academic and financial assistance records from the educational instituäons he or she is now attending and from all institutions he or she will attend in the future. This access is needed to track my son or daughter's academic progress in accordance with the Upward Bound Program's Annual Reporting Requirements determined by the U.S. Deparünent ofEducation.
Parent of Guardian Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy

STUDENT INFORMATION RELEASE AUTHORIZATION FORM
Parent/Guardian's Name*

First NameLast Name
Child's Name*

First NameLast Name
I,{name91}, do authorize the staff of the Community Teen Coalition Upward Bound Program to obtain copies of {name92}'s transcripts, report cards and all test scores throughout his/her high school years.

I understand that this information will be held in strict confidence and will be used to evaluate my child's progress to determine the effectiveness of the services rendered by the Upward Bound Program.
Parent of Guardian Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy

Recommendations
Please provide the name and email of a Counselor and a Teacher you would like to have recommend you for our program.
Counselor Name*

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

First NameLast Name
Teacher Email*
example@example.com

Community Teen Coalition Upward Bound Student Self Assessment
NAME:*

First NameLast Name
Date*

MonthDayYear
mm-dd-yyyy
Instructions: To help Upward Bound Staff develop a plan of services for you. we must know what you need. Please read through the following lists and indicate whether you feel you have a "high need". "some need", or "no need" for help or improvement in that area.

ACADEMIC SKILLS

English and writing skills:*

	High Need	Some Need	No Need
Spelling
Grammar
Punctuation
Organizing your writing
Writing essays and reports
Verbal expression (speaking skills)
English as a second language

Reading skills:*

	High Need	Some Need	No Need
Improving vocabulary
Reading speed
Comprehension (understanding)
Retention (remembering what you read)

Math skills:*

	High Need	Some Need	No Need
Basic arithmetic
Basic Algebra
Advanced math

Science & Social Studies skills:*

	High Need	Some Need	No Need
Science skills
Social Studies skills

Learning and study skills:*

	High Need	Some Need	No Need
Time management
Developing good study habits
Studying for and taking tests
Taking notes in class
Developing library skills

Careers:*

	High Need	Some Need	No Need
Setting educational goals
Exploring career options
Identifying career interests
Identifying career aptitudes

Personal motivation:*

	High Need	Some Need	No Need
Improving school/class attendance
Studying/doing homework
Improving attitude toward school
Setting goals and priorities

Personal counseling:*

	High Need	Some Need	No Need
Improving interpersonal skills
Building self-confidence
Working through a personal problem
Drug or alcohol use or abuse

College Admissions:*

	High Need	Some Need	No Need
Admission requirements
Identifying and applying for scholarships
Financial Aid
Deciding which college to attend

Are there other academic or personal areas in which you would like assistance or counseling? If yes, please explain:*
Community Teen Coalition Upward Bound

Student Essay
Instructions: Please write a 1-page essay telling us about yourself. Include your future plans and reasons for wanting to be in the Upward Bound Program. Creativity is welcome as well, if you would like to draw to illustrate who you are.*
Optional Illustration

Cancelof

Community Teen Coalition

Upward Bound Program

Participant Application

Parent/Guardian One

Parent/Guardian Two

Community Teen Coalition Upward Bound

Student Essay