Partners In Ministry-UB-Counselor Referral

Applicant Name

First NameLast Name

Grade

Dear Counselor/School Advisor

The above named person is interested in becoming a participant in Partners In Ministry Upward Bound Program. Upward Bound is an early intervention pre-college program that helps students prepare for higher education. The Upward Bound Program provides academic support designed for participants to succeed in their preparation for college entrance and ultimately in their pursuit in post-secondary degrees after high school graduation.

Your referral will be used as a part of the Upward Bound application process. Please complete the information based upon your knowledge of the applicant. Thank you for your assistance.

Academic Performance

GoodAverageBelow average

Grade Point Average

School Attendance

RegularIrregular

Applicant experienced social, physical, or psychological problems?:

YesNo

Comments:

Does the applicant intent to pursue postsecondary education?

YesNo

Results of Standardized Tests

PSAT:

ACT:

SAT:

Applicant needs support in the following areas:

Do you recommend this student for participation in the Upward Bound Program

YesNo

School Counselor/Advisor Name*

First NameLast Name

Email*

example@example.com

Signature

Date

mm-dd-yyyy

COUNSELOR REFERRAL FORM