Greater Houston Community Partner-UB-Application Form

APPLICANT INFORMATION

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone:

(999)999-9999

Cell Phone:*

(999)999-9999

E-Mail Address:*

example@example.com

Social Security Number:

999-99-9999

Name of High School:*

Willowridge High SchoolMarshall High School

Grade*

9101112

Gender

MF

Age:

Date of Birth:*

mm-dd-yyyy

Student ID #:

ETHNIC BACKGROUND*

CITIZENSHIP STATUS*

US CitizenUS Permanent ResidentOther

Permanent Resident Number :

HIGH SCHOOL COURSES (Check all that apply.)

SCHOOL ACTIVITIES

Organizations:

Sports:

EMPLOYMENT

Not EmployedWeekends OnlyPart-timeFull-Time

Hours Per Week:

CAREER ASPIRATIONS: What career or type of career are you interested in?

ACADEMIC ASPIRATIONS:

ACADEMIC/NON-ACADEMIC NEEDS AREAS: (Check all areas in which you need help.)

To be completed by the parent or guardian of applicant:

FATHER OR MALE GUARDIAN

Relationship to applicant:

Name:

First NameLast Name

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone:

(999)999-9999

Work Phone:

(999)999-9999

Email

example@example.com

Employer:

Occupation:

Highest grade completed:

(Check all that apply.)

Mother OR FEMALE GUARDIAN

Relationship to applicant:

Name:

First NameLast Name

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone:

(999)999-9999

Work Phone:

(999)999-9999

Email

example@example.com

Employer:

Occupation:

Highest grade completed:

(Check all that apply.)

FAMILY INFORMATION

Who does the applicant currently live with?*

Primary language spoken at home?

Does home have access to a computer?

YesNo

Does home have access to the Internet?

YesNo

How many people live in the household?

Adults

Children

How many people in the household total:*

Does the family qualify for free/reduced lunch?*

YesNo

Does the family qualify for Temporary Assistance for Needy Families?*

YesNo

Does the family receive any of the following?

A copy of your most recent U.S. Income Tax Forms will be required at the parent/student interview in order to verify annual taxable income.

I certify that the above information is correct. I understand all information obtained will remain confidential. This information will be used to verify eligibility and to provide statistical data in compliance with federal and state regulations. I also give my consent to allow ACHIEVE Upward Bound Program to obtain transcripts and any educational records that pertain to my child’s academic progress.

Parent/Guardian Signature:*

Date:

mm-dd-yyyy

STUDENT ESSAYS

Please write a brief description of yourself, your interests and/or your values.*

Please write a paragraph describing why you want to participate in the Upward Bound Program and what you hope to gain from the program.*

T-Shirt Size*

List three personal or academic strengths:

1.

2.

3.

List three personal or academic areas in which you would like to improve:

1.

2.

3.

How did you hear about Upward Bound?