THE UNIVERSITY OF TENNESSEE TRiO / Pre-College Upward Bound
Personal Information
School:
*
Carter HS
Gibbs HS
Heritage HS
Northview Academy
Sevier County HS
South-Doyle HS
West HS
William Blount HS
Other
Name:
*
First Name
Middle Name
Last Name
Social Security Number:
999-99-9999
Date of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age:
Home Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address / P.O. Box:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Student's Cell Phone:
(999)999-9999
Student's Email Address:
*
example@example.com
Gender:
Male
Female
Ethnicity/Race:
African-American / Black
Alaskan Native
Asian
White
Hispanic / Latin(x/e)
Native American
Native Hawaiian / Pacific Islander
Other
Are you a US Citizen or Permanent Resident?
Yes
No
If NO, Alien Registration Number:
Do you have a disability?
Yes
No
If YES, please describe:
Physical
Learning
Emotional
What accommodations will you need, if any?
Is English your primary spoken language?
Yes
No
If NO, what language do you primarily speak?
Parent / Guardian Education and Employment
With whom do you currently live?
Both parents
Mother and Stepfather
Father and Stepmother
Grandparent(s)
Mother only
Father only
Foster parent(s)
Ward of the court
Other
Name (Parent / Guardian One):
Name (Parent / Guardian One):
First Name
Last Name
Phone number:
(999)999-9999
Email Address:
example@example.com
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation:
Employer:
Business phone:
(999)999-9999
Check all that apply to Parent / Guardian One only:
Did not complete high school
Completed high school
GED/HISET
Certificate / trade program
1-3 years of college
4-year college / university graduate
Name (Parent / Guardian Two):
Name (Parent / Guardian Two):
First Name
Last Name
Phone number:
(999)999-9999
Email Address:
example@example.com
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation:
Employer:
Business phone:
(999)999-9999
Check all that apply to Parent / Guardian Two only:
Did not complete high school
Completed high school
GED/HISET
Certificate / trade program
1-3 years of college
4-year college / university graduate
High School Information
Current Grade Level:
9th
10th
11th
12th
Expected Graduation Date:
Current High School:
Name of your school counselor:
Educational Plans
Educational plan after high school:
4-year college / university
2-year college
TCAT
What are your career goals?
How did you become interested in this career?
List your extracurricular activities and any honors and awards you have received.
Self-Report Questionnaire
1. Going to college after high school:
is something I am determined to do
is something I've seriously considered
is something that occasionally crosses my mind
is something that I am NOT interested in
2. Three careers I have considered pursuing are:
3. My favorite classes in high school are:
4. My least favorite classes in high school are:
5. Please check the academic areas in which you excel:
Language Arts
Writing
Math
Science
Computers
Art/Drama
History
Social Sciences
Other
6. I plan to complete the following educational level:
High School Diploma
Military
Technical college or certificate program
Associate's Degree (2-year degree)
Bachelor's Degree (4-year degree)
Graduate/Professional degree (Master's, Ph.D., etc.)
7. Three things I am proud of are:
8. Three goals I have for myself are:
9. Which of the following would be the most likely reason that youwould not achieve your educational goals? (Select all that may apply.)
Lack of financial resources
Lack of motivation
Lack of interest in school
Low standardized test scores
Entrance into workforce
Military
Signature of Student:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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