BRCC UPWARD BOUND
201 Community College Drive
Baton Rouge, LA 70806
225.216.8135 • Fax 225.216.8669
Dear Applicant and Parents/Guardians
On behalf of the administration, faculty and staff, we would like to thank you for your interest in applying to the Upward Bound
Program at Baton Rouge Community College. The goal of the program is to develop in its participants the academic skills and
motivation necessary for successful completion of high school and college.
Potential candidates for Upward Bound must commit to preparing themselves for post-secondary education before being
accepted into the program. In return, Upward Bound provides its participants with a wide range of free services — tutoring,
counseling, classroom instruction, college and career guidance, aimed at improving their academic skills and their motivation and
determination to pursue a post-secondary education.
Once your application is completed, please return it to the Upward Bound Office. PLEASE DO NOT FAX THE APPLICATION or
any of the requested documentation. Also, please submit a copy of supporting documents, such as grades, transcripts, social
security cards, and income information. DO NOT SUBMIT ANY ORIGINAL COPIES.
Program eligible students will be selected from those who complete an application and will be invited for an interview. Please
note that the completion of this application does not guarantee program admission. Completed applications of students
who are not selected as program participants during any given recruitment period are maintained on a waitlist until an opening
occurs.
If you have any questions, please call 225.216.8135.
THANK YOU FOR YOUR INTERESTS!
BRCC UPWARD BOUND
201 Community College Drive
Baton Rouge, LA 70806
225.216.8135 • Fax 225.216.8669
Applicant Information
Date
Name
Address/P.O. Box Number
first
middle
last
street
city
state
Apartment Name (if applicable)
Age
zip
Apartment No. (if applicable)
Social Security No.
High School
Date of Birth
Name of Parents/Legal Guardian
Student’s e-Mail Address
Current Grade Point Average
Sex
o Male o Female
Parish
Home Phone No.
(
)
Parent’s/Legal Guardian’s Work No.
(
)
Parent’s/Guardian’s e-Mail Address
Are you in another pre-college program?
Citizenship:
o U.S. Citizen o Permanent Resident
Name of Emergency Contact 1.
What is the name of the program?
Current Grade
Alternate Phone No. (cellular phone)
(
)
How long have you been a participant?
o Yes o No
Country of Birth Please attach a copy of supporting
o Eligible Non-Citizen
documentation, i.e., resident alien card.
Relationship
Phone No.
Name of Emergency Contact
2.
Relationship
Phone No.
Name of Emergency Contact
3.
Relationship
Phone No.
Background Information
Check one of the following blocks:
o African-American/Black
o Asian-American/Asian/Pacific Islander
o European-American/Anglo/Caucasian
o Hispanic-American/Latino/Chicano
o Native American/American Indian
o Bi-racial (specify)
o Other (specify)
Are you physically challenged or have any
Do you live in foster care?
If yes, identify on and attached sheet.
certified learning disabilities? o Yes o No
o Yes o No
Have you taken the ACT?
Have you taken the SAT?
Do you plan to attend college? (If no, explain in the blank area below.)
o Yes o No
o Yes o No
o Yes o No
If yes, which college?
What is your intended occupation?
Are you currently employed?
Where?
o Yes o No
What extra curricular activities are you involved in at school?
Hours Per Week
What extra curricular activities are you involved in your community?
Section A.
Family Information
ONLY PARENTS/LEGAL GUARDIANS SHOULD RESPOND TO SECTIONS A-D.
ALL INFORMATION WILL BE HELD IN THE STRICTEST CONFIDENCE
We are required by the United States Department of Education to obtain income information from all applications served by the Upward
Bound TRIO Program.
To be completed by Parents/Legal Guardians ONLY.
Applicant lives with
o Both Parents
o Mother
o Father
o Other (specify)
If adopted or in foster care, is this recognized
In what state?
Written verification must be provided.
o Yes o No
through a court of law?
Did you or your spouse attend but not complete college?
Verification of parent’s/legal guardian’s Degree Status
o Yes
o No
Form must be completed and attached to this application.
Name of the head of the household first
last
Relationship to applicant?
As head of the household, do you claim the applicant as a dependent on your tax form?
o Yes
o No
If no, explain on separate sheet of paper
List all family members who live in the household, including the applicant.
Name
Age
Relationship
Grade
to Applicant
Level
Applicant
Section B.
Check if
Receiving
Free/Reduced
Lunches at
School
Check if Attending College
Check if
Employed
Documentation of Income
Number of family members claimed in the household as dependents on your taxes? Form used?
o Yes o No
o 1040
What is you taxable income?
Indicate tax year applicable
o 1040EZ o I do not file taxes
A copy of your most recent income tax statement must be attached to this application. Please do not submit copies of W-2 forms/check stubs.
Does your family receive income from any of hte sources listed below? Check all applicable and indicate dollar amount received.
o Food Stamps $_________________ o SSI $_________________
o VA/GI Bill $________________
o Pension/Retirement $___________ o Alimony $_____________
o Child Support $____________
A statement from your caseworker or a copy of a document confirming this information must be attached to this application.
Section C.
Parental Involvement
One of the goals of the Upward Bound Programs is to encourage parents/legal guardians to support participation in the development of student’s academic
progress. As an Upward Bound parent, you would be expected to attend meetings, workshops, and provide support to your child while in the program. Please list
the top two things that you want Upward Bound to do for your child, if he/she is chosen for admission to the program.
1.
2.
Certification
PLEASE READ THIS SECTION CAREFULLY AND THOROUGHLY BEFORE SIGNING.
The Federal Government through the Department of Education funds the Upward Bound Trio Program at the Baton Rouge Community College.
Applicants are admitted regardless of race, color, national or ethnic origins, or physical challenges. Ther personal information that you provide to the
Upward Bound TRIO Program is available upon request to the United States Department of Education, Baton Rouge Community College, and federal
and state auditors. Each of these agencies has the authority to gather information on the Upward Bound TRIO Program. The Information that you
submit therefore becomes the property of the Upward Bound TRIO Program and its affiliates. In accordance with the Privacy Act of 1974, agencies
other than those authorized are prohibited access to the files and records of the Upward Bound TRIO Program. Applicants, parents, and legal
guardians are reminded that the affiliates of the Upward Bound TRIO Program have the authority to verify the information herein. Misrepresentation of information is a serious offense and because of the involvement of federal funds, any misrepresentation may lead to fines/imprisonment.
My signature certifies that all information provided herein this application is true to the best of my knowledge. I further understand that admission
of applicants granted to the Upward Bound TRIO Program on the basis of incorrect information or an omission of fact, which if known, would have
caused ineligibility of my child, is invalid and subject to action by the appropriate authorities.
I understand that all records will be kept in the strictest confidence in accordance with the Privacy Act of 1974.
Print Name of Responsible Parent/Legal Guardian
Date
Signature of Responsible Parent/Legal Guardian
Date
Print Name of Applicant
Date
Signature of Applicant
Date
Application Checklist
To be considered for selection into the Upward Bound Program, the following must be submitted:
o Completed and signed Application
o Notarized Degree Status Form
o 1 letter of referral from a mathematics, English, or science teacher
o Copy of Appliant’s transcript
o Copy of Applicant’s current grades and LEAP results
o Copy of Parent’s/Legal Guardian’s current 1040 Income Tax Return/Verification of Income
o Copy of Applicant’s Social Security Card
o Copy of State Standardized Examination Scores
All of the above items/forms must be attached to the application when it is notarized. Incomplete applications will not be considered.
The following documents will be completed after the applicant is notified of pending selection and before the applicant is officially admitted as a participant in the Upward Bound Program.
o Invitation Acceptance Form
o Participant Health Record and Authority to Render Medical Services Form
o Emergency Contact Form/Family Information Form
o Permission Form for fieldtrips and special activities
o Parent/Guardian Survey
o School Release Form of Records
o Student Agreement
o Request for Taxpayer Identification Number and Certification (participant ONLY)
o Course Enrollment Survey
o Activities Survey
o Summer Food Application (if selected during summer session)
o Others
Thank you for Applying for the Upward Bound Program!
Teacher Referral Form
The purpose of this form is to gather information on each application to determine those who will best be served by the Upward Bound
Program at Baton Rouge Community College. Please frankly document your evaluation of this applicant's ability to benefit from these program
services. Keep in mind that the purpose of Upward Bound is to generate skills and motivation essential for post-secondary educational
achievement. Applicants must possess the ability to pursue post-secondary education, but may not be able to do so without the services
provided by the Upward Bound TRIO Program.
Applicant's Name
Length of Acquaintance School
Grade
Classes in which you have taught applicant
How would you describe the applicant's motivation to complete high school? (check the appropriate box)
o Strong (plans to go to college)
o Fair (plans to graduate)
o Weak (his risk for non-competition)
o Cannot access
How would you describe the applicant's performance in class? (check all that apply)
o Attentive/focused
o Turns in work on time
o Asks questions in class
o Works hard
o Takes notes
o Does well on tests
o Reads well
o Is creative
o Turns in neat, well-organized work
o Strong math skills
o Strong science skills
o Strong writing skills
o Strong verbal skills
o Disruptive
o Inattentive
o Easily distracted
o Often turns in work late/not at all
o Must improve communication with teacher
o Must improve amount of effort put forth
o Never takes notes
o Does poorly on tests
o Must improve reading skills
o Put little expression into work
o Must improve quality of work
o Must improve math skills
o Must improve science skills
o Must improve writing skills
o Must improve verbal skills
o Must improve behavior
o Must improve attention span
Check the skills/aptitudes that apply to applicant (check all that apply)
o Outgoing
o Creative
o Involved in school activities
o Strong willed
o Committed to family
o Strong community involvement
o Balances work/school well
o Exhibits leadership
o Responsible
o Bilingual
o Role model
o Positive influence
o Overcomes obstacles
o Well organized/prepared
Signature
Date
Position
Teachers: Your assistance in completing this form is appreciated. Please include any additional comments that would help in the evaluation of this applicant (attach
additional pages, if necessary). Once completed, return the referral form as soon as possible to the student applicant or school counselor. The application will not
be complete until this form is submitted.
NOTARY
The Upward Bound TRIO Programs
SEAL
Baton Rouge Community College
Baton Rouge, Louisiana
VERIFICATION OF PARENT'S/LEGAL GUARDIAN'S DEGREE STATUS FORM
This form must be completed and signed by the applicant's parent/legal guardian. It must be
NOTARIZED and ATTACHED with the application documents.
Applicant's Name
I, FIRST
MI
LAST
hereby certify before the presence of a Notary Public the following:
PLEASE CHECK THE RESPONSE THAT APPLIES TO YOU:
o I am not a graduate of a four-year college/university
o I am a graduate of a four-year college/university
o My spouse is not a graduate of a four-year college/university
o My spouse is a graduate of a four-year college/university
Signature(s) of Parent(s)/Legal Guardian(s):
Date
Date
Notary Signature:
Date
APPLICANTS WILL NOT BE CONSIDERED FOR ADMISSIONS UNTIL THIS FORM IS COMPLETED AND SUBMITTED.
For additional information/questions, call 225.216.8135
Student Needs Assessment
This survey contains a number of statements about student needs. Please give your honest opinion on how the Upward Bound Program can
meet your needs. Your answers are kept confidential.
ACADEMIC NEEDS (Circle the value that applies):
1. To learn how to complete and turn in my homework on time
2. To get better grades
3. To better organize my time, activities, and responsibilities
4. To learn more about high school requirements for college
5. To listen better in class and ask more questions
6. To take tests better and with less anxiety
7. To relate to and communicate better with my teachers
8. To identify, set, and evaluate goals for the future
Strong
Need
1
1
1
1
1
1
1
1
Some
Need
2
2
2
2
2
2
2
2
No Need
Strong
Need
1
1
1
1
1
1
1
1
Some
Need
2
2
2
2
2
2
2
2
No Need
Strong
Need
1
1
1
1
1
1
Some
Need
2
2
2
2
2
2
No Need
3
3
3
3
3
3
3
3
My academic goal is:
1.
2.
3.
4.
5.
6.
7.
8.
To better understand my parents and other adults
To learn to deal with conflict in a positive manner
To be more accepting of my physical appearance
To learn how my self-esteem affects my behavior
To learn how to get along better with members of the opposite sex
To accept greater responsibility for my actions
To learn more about the use/abue of drugs/alcohol
To learn to accept people who are different from me
3
3
3
3
3
3
3
3
My personnel goal is:
1.
2.
3.
4.
5.
6.
To explore a variety of career opportunities
To learn more about job applications, résumés, and interviews
To learn more about post-secondary admission processes
To prepare for exams like the PSAT, ACT, or SAT
To visit more colleges
To learn about college costs and how to pay for college
3
3
3
3
3
3
Name a college that you would like to visit:
Print Applicant's Name
Applicant's Signature
Date