268631-LULAC National Educational-Albuquerque-UB 5-Application Form-Ian

Dear Parent/Guardian:

Your child has indicated an interest in the LNESC Upward Bound (UB) Program. Upward Bound (UB) is a FREE college preparatory program for high school students funded by the U.S. Department of Education and sponsored locally by LULAC National Educational Service Center (LNESC). UB is specifically designed to strengthen the academic skills of eligible high school students to excel academically and ultimately pursue a postsecondary degree after high school graduation.

Services provided by UB include:
- Tutorial services during the school year to strengthen academic skills and prepare students for college
- Academic advising and individual assistance with college admissions and financial aid application process
- Saturday Academies, once a month to educate students on various college, career, and life skills concepts
- A 6-week summer instructional component that is designed to simulate a college-going experience that includes daily coursework in English, Math and Science as well as other related activities such as field trips and special events
In order to comply with federal regulations, we gather income, citizenship and other qualifying information. All of the information you provide is protected by the Privacy Act. Only LNESC Upward Bound staff have access to the information provided. ALL UB participants must meet the following criteria:
- Be a citizen of the U.S or permanent resident
- Indicate an interest in attending college
- Demonstrate academic need
- Qualify as low-income and/or neither parent has graduated from college with a bachelor’s degree
- Commit to remain active in UB through high school graduation
All completed applications will be reviewed and eligible applicants contacted within 14 days for a Student & Parent Interview. If your child is selected to participate in Upward Bound, we highly encourage parents to attend ALL Parent/Teacher Conferences. Thank you for your interest in the Upward Bound Project. Please feel free to contact the LNESC office at (505) 243-3787 if you have any questions or need additional assistance.

Personal Essay
The personal essay is an important part of the selection process and must be completed by student. Your final essay will be evaluated for thoughtfulness of content. Discuss the following topics. Please attach additional pages if necessary.
What are your goals after graduating high school?*
How will Upward Bound assist you in achieving these goals?*
What skills, experience, and knowledge can you share with others in Upward Bound?*
Why would you like to be a member of the LNESC Upward Bound program?*
Additional Pages

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Family Information
NOTE: The information you provide is protected by the Privacy Protection Act. Only authorized UB personnel will see the information.
Parent/Guardian #1*

First NameMiddle NameLast Name
Highest Level of Education Completed*

Some High SchoolDiploma/GEDSome College2-year college degree4-year college degreeOther
Marital Status*

SingleMarriedSeparatedDivorcedWidowed
Name of Employer*
Work Phone Number*
(999)999-9999
Email Address*
example@example.com
Best Telephone Number to be Reached*
(999)999-9999
Parent/Guardian #2

First NameMiddle NameLast Name
Highest Level of Education Completed

Some High SchoolDiploma/GEDSome College2-year college degree4-year college degreeOther
Marital Status

SingleMarriedSeparatedDivorcedWidowed
Name of Employer
Work Phone Number
(999)999-9999
Email Address
example@example.com
Best Telephone Number to be Reached
(999)999-9999
Family Financial Information
How many family members living in your home do you support financially? *
Does the family/student receive or qualify for any of the following? (Check all that apply)*

Free/Reduced LunchFood StampsUnemployment (specify amount below)SS/SSIPublic HousingTANFWomen, Infants, Children (WIC)NoneOther
If unemployment, how much?
What was your taxable income for 2023?
Please Refer to IRS Form 1040: Line 43; IRS Form 1040A: Line 27; IRS Form 1040EZ: Line 6)
Please attach a copy of last year’s U.S. Income Tax Return (2023)

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If you did not file a tax return, please indicate your untaxed income. (This information is used for qualifying purposes only)

	Dollar Amount
Wages
Business Income
Other (retirement etc.)

Emergency Contact*

First NameMiddle NameLast Name
Relationship to Student*
Phone Number*
(999)999-9999
My signature below indicates that the information on this application is true and accurate to the best of my knowledge.
Parent/Legal Guardian's Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy

Parent Release
The information requested authorizes media release, school records release, and internet use release. The form also requests medical information and authorizes medical treatment in case of emergency. LNESC is able to provide these free services through a grant from the U.S. Department of Education under TRIO’s Upward Bound Program. The Federal Privacy Act and Family Rights and Privacy Act protect the personal information you give on this application. This application is confidential when completed.

Media Publication Release Authorization

I hereby grant LNESC full and absolute permission and all rights to copyright, publish, display, and use for any legal purpose or all photographs, together with descriptive text or statements, in which I or my property or my child appear.
Parent/Legal Guardian's Initial*
Release of School Records

As the parent and/or legal guardian of the student listed above, I grant the LNSEC Upward Bound Project permission to obtain copies of my child’s academic grade reports, transcripts, and/or standardized test scores from the school to assist my son/daughter in achieving his/her educational goals. I also grant the UB staff my permission to speak with teachers, counselors and other school administrators at my child’s school in order to obtain and exchange information as part of the services provided by the UB Project.
Parent/Legal Guardian's Initial*
Internet Use Release

I hereby grant permission for my child to access networked computer services such as Internet, World Wide Web and electronic mail at the LNESC computer lab.
Parent/Legal Guardian's Initial*
COVID-19

Although it is not required to be vaccinated to join Upward Bound, it is LNESC's policy that students attending Upward Bound activities or field trips outside of APS must be fully vaccinated. No Exceptions!
Is the student vaccinated for Covid-19?*

YesNo
Please attach copy of Vaccination Card.*

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Parent/Legal Guardian's Initial*
Medical Information and Parental Consent
Is the student covered by any medical insurance?*

YesNo
If yes, please complete the following.
Name of Insurance Co.
Insurance Policy Number
Name of Physician

First NameLast Name
Office Telephone
(999)999-9999

Please list any medical conditions including allergies and physician prescribed medicine that the student is currently taking (if none, please type non on row #1)*

	List Medication/Medical History	Allergies	Allergic Reaction
1
2
3
4

As the parent/guardian of the above named student, I hereby authorize LNESC Upward Bound provide medical diagnostic and/or authorize the medical and/or surgical treatment of my child as may be necessary or appropriate under the circumstances for treatment of any illness or injury of my child. LNESC and its employees, and officers will not be liable in any way for any consequences from said diagnostic, medical and/or surgical treatment and are hereby released from any and all claims and causes of action that may arise out of such diagnosis, treatment or surgery to the extent allowed by law. Furthermore, LNESC does not assume any financial or other responsibility, but wishes to provide the best services possible in case of emergency.
Parent's/Legal Guardian's Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy