TRiO/Upward Bound Math & Science
College of the Sequoias
915 S. Mooney Blvd. - Visalia, CA 93277
Phone: (559) 737-5400
www.cos.edu
Application Checklist
Student’s Name:
High School:
Date:
Grade Level: _____ 9th _____ 10th _____ 11th HS ID #:
Completed TRiO/UBMS application
SECTION A
A1: Student Information
Copy of student’s Social Security and/or Legal Residency card
SECTION B
B1: Parent/Guardian Information
B2: Household/Income Information
Signed copy of IRS 1040 and/or complete Income Verification
SECTION C
C1: Signature
Student
Parent/Guardian
SECTION D: Authorization for Academic Records/Transcript Release
SECTION E: Student Personal Essay
SECTION F: Teacher Recommendation Form
SECTION G: Counselor Recommendation Form
SECTION H: Student Health Form
SECTION I: Student Pledge
Transporting Permit
High School Transcripts and/or latest Grade Report
Contact TRiO/UBMS Program Staff with any questions concerning the TRiO/Upward Bound Math &
Science Program and its application process.
TRiO/Upward Bound Math & Science
College of the Sequoias
915 S. Mooney Boulevard
Visalia, CA 93277
(559) 737-5400
TRiO/Upward Bound Math & Science
College of the Sequoias
915 S. Mooney Blvd. - Visalia, CA 93277
Phone: (559) 737-5400
www.cos.edu
Program Application
Personal information is protected by the Privacy Act of 1974; only authorized individuals and the U.S.
Dept. of Education access to the information provided. The information provided is used to determine
eligibility to the TRiO/Upward Bound Math & Science Program at College of the Sequoias.
The TRiO/UBMS at COS ensures that participants will be considered without regard to race, color,
national origin, religious belief, gender and/or persons with disabilities.
SECTION A:
A1.
TO BE COMPLETED BY THE STUDENT
Student Information
Name:
Last Name
First Name
M.I.
Address:
Street Address
City
State
Zip Code
City
State
Zip Code
P.O. Box (if applicable):
P.O. Box #
Phone Number: (
)
(
Area Code
Home Phone #
)
Area Code
Cell Phone #
Email:
Date of Birth:
/
Month
/
Day
Gender: Male
Female
Year
Social Security Number:
-
-
Please include copy of SS card
Are you a U.S. Citizen?
YES
NO
If no, please include a photo copy of Legal Residency card
Race/Ethnic Origin:
Hispanic/Latino
Asian
White
American Indian/Alaskan Native
Native Hawaiian or Pacific Islander
Black or African American
Current Grade:
9th
Current School:
Lindsay High School
Orosi High School
10th
11th
Farmersville High School
Woodlake High School
School Counselor:
Name
Office Phone #
2
SECTION B:
B1.
TO BE COMPLETED BY THE STUDENT’S PARENT/GUARDIAN
Parent/Guardian Information
Mother/Guardian:
First Name
Last Name
Occupation
Contact Information:
Street Address
Home #
City
cell #
State
work #
Zip Code
email
Father/Guardian:
First Name
Last Name
Occupation
Contact Information:
Street Address
Home #
City
cell #
Please indicate highest grade level completed:
State
work #
Zip Code
email
Mother/Guardian
Father/Guardian
Elementary (k-8)
High School (9-12)
Some College
2 Year College Degree
4 Year College Degree
Other:
B2.
Household/Income Information
Federal Regulations require the TRiO/Upward Bound Math & Science Program at College of the
Sequoias to obtain household information and income documentation to determine eligibility for each
student applying to participate in TRiO/UBMS.
Number of family members living at home:
Adults
Have you filed an Income Tax Return?
Yes, attach a signed copy of most recent IRS 1040
No, please complete the following
SSA/SSI:
A/GI Bill:
TANF:
Welfare:
$
$
$
$
Unemployment:
Food Stamps:
Pension/Retirement:
AFDC:
Other (specify):
SECTION C:
C1.
Children
$
$
$
$
$
TO BE COMPLETED BY STUDENT & PARENT/GUARDIAN
Signatures
This is to certify that all information given by me is true and correct to the best of my knowledge.
Student:
Print Name
Signature
Date
Print Name
Signature
Date
Parent/Guardian:
3
SECTION D:
D1.
TO BE COMPLETED BY STUDENT & PARENT/GUARDIAN
Authorization for Academic Records/Transcript Release
I give the TRiO/Upward Bound Math & Science Program at College of the Sequoias permission to
receive copies of my educational records and other materials necessary for participation in the program
and to release educational records to educational institutions.
Further permission is granted to request academic and financial aid information and records from any
and all postsecondary institutions to track college progress.
I understand that my personal information will be kept in confidence and in accordance with the Privacy
Act of 1974 and only authorized individuals and the U.S. Dept. of Education have access to the
information provided.
I understand that the information provided is used to determine eligibility to the TRiO/Upward Bound
Math & Science Program at College of the Sequoias and does not guarantee me acceptance into the
Program.
I understand that TRiO/UBMS at COS ensures that participants will be considered without regard to
race, color, national origin, gender and/or persons with disabilities.
Student:
Print Name
Signature
Social Security Number
Date
Date of Birth
Parent/Guardian:
Print Name
Signature
Date
The College of the Sequoias Upward Bound Math & Science Program will treat all eligible applicants equally, regardless of race, color,
national origin, gender, sexual orientation, religion or physical disability. College of the Sequoias, in compliance with Titles VI and VII of
the Civil Rights Act of 1964, Executive Order 11246 as amended, Title IX of the Education Amendments of 1972 (Higher Education Act),
Americans with Disabilities Act of 1990, and other federal laws and regulations, does not discriminate on the basis of race, color, national
origin, sex, age, religion, handicap, or status as a veteran, in any of its policies, practices or procedures. This provision includes, but is not
limited to, admissions, employment, financial aid and educational services.
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SECTION E:
E1.
TO BE COMPLETED BY THE STUDENT
Student Personal Essay
Please write or attach a typed short personal essay focusing on the topics listed below. Do not limit
yourself to the list of topics; feel free to share with us any other interesting stories about yourself and
your family. Attach extra sheets if needed.
1.
Write about your background, interesting events in your life and where and how you were raised.
2.
Write about school. What are your plans after high school, after college, etc?
3.
What are your plans for the future? College, career and personal goals. What do you see yourself
doing ten years from now?
4.
Explain how you would benefit from being part of the TRiO/UBMS at COS.
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TRiO/Upward Bound Math & Science
College of the Sequoias
915 S. Mooney Blvd. - Visalia, CA 93277
Phone: (559) 737-5400
www.cos.edu
SECTION F:
F1.
TO BE COMPLETED BY STUDENT’S TEACHER
Teacher Recommendation Form
Name of Student:
9th
Current Grade:
10th
11th
To the teacher: This student is applying to the TRiO/Upward Bound Math & Science Program at the
College of the Sequoias. TRiO/UBMS is designed to assist participating students in preparing for and
enrolling in a college-level educational program. Students who show potential but need motivational
and/or academic or other personal assistance in order to succeed in a college-level program may apply.
Please be as specific as possible in your remarks. Your comments and evaluation will be confidential.
Teacher’s Name:
Date:
High School:
Contact Information:
Phone Number
1. How long have you known the applicant?
Email
month(s)
2. Under what circumstances?
Based on your knowledge of the applicant, please rate his/her academic skills:
Outstanding
Above
Average
Average
Academic
achievement
Math skills
Reading skills
Study skills
Writing skills
Comprehension
skills
Use of time
Organization
Additional Comments:
6
Needs
Improvement
No Basis
for Judgment
F1.
Teacher Recommendation Form (cont.)
Please rate the applicant’s characteristics and motivation:
Outstanding
Above
Average
Average
Needs
Improvement
No Basis
For Judgment
Ability to cope calmly with
frustrating experiences
Demonstrates Leadership
Capability
Interpersonal skills
Self-image
Potential for growth
Potential to succeed
Motivation and willingness to learn
Tolerance of minor
disappointments
Intellectual curiosity
Ability to work with others on
group projects
Quality of work submitted
Emotional maturity
Attentiveness in class
Ability to meet deadlines
Potential to appreciate and
maximize learning opportunities
1. What services or assistance does the student need to help him/her succeed in high school (i.e.,
tutoring, counseling, college information)?
2. What is your assessment of the student’s potential to succeed in high school and continue onto
college?
3. What other qualities come to mind that best describes this applicant?
Additional Comments:
Teacher’s Signature:
Date:
PLEASE RETURN TO STUDENT IN A SEALED ENVELOP
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TRiO/Upward Bound Math & Science
College of the Sequoias
915 S. Mooney Blvd. - Visalia, CA 93277
Phone: (559) 737-5400
www.cos.edu
TO BE COMPLETED BY STUDENT’S COUNSELOR
SECTION G:
G1.
Counselor Recommendation Form
Name of Student:
Current Grade:
9th
10th
11th
To the counselor: This student is applying to the TRiO/Upward Bound Math & Science Program at the
College of the Sequoias. TRiO/UBMS is designed to assist participating students in preparing for and
enrolling in a college-level educational program. Students who show potential but need motivational
and/or academic or other personal assistance in order to succeed in a college-level program may apply.
Please be as specific as possible in your remarks. Your comments and evaluation will be confidential.
Counselor’s Name:
Date:
High School:
Contact Information:
Phone Number
Email
1. Which of the following best describes this student’s high school curriculum?
Academic/College Prep
Honors Program
General
Vocational
___ Remedial
___ Other
2. What is the student’s approximate class rank?
Top 10%
Top 25%
Top 50%
Below 50%
3. What is the student’s reading level?
Above
At
Below Grade Level
4. How would you rate the student’s attendance?
Excellent
Good
Fair
Poor
5. Has this student ever been subject to disciplinary action or suspension?
Yes
No
Explain:
6. Please indicate your recommendation of the student for participation in TRiO/UBMS
Strongly Recommend
Recommend with Reservations
Recommend
Do not recommend
Additional Comments:
Counselor’s Signature:
Date:
PLEASE RETURN TO STUDENT IN A SEALED ENVELOP
8
TRiO/Upward Bound Math & Science
College of the Sequoias
915 S. Mooney Blvd. - Visalia, CA 93277
Phone: (559) 737-5400
www.cos.edu
SECTION H:
H1.
TO BE COMPLETED BY STUDENT’S PARENT/GUARDIAN
Student Health Form
Student Information:
Name:
Last Name
First Name
M.I.
Address:
Street Address
Date of Birth:
City
/
Month
State
/
Day
Zip Code
Gender: Male
Female
Year
Medical Information:
Medical Insurance:
Insurance Name
Policy #
Family Doctor:
Name
Address
City
Phone #
Student’s Health Conditions (check those that apply):
___ Allergies & Allergic Reactions
Specify: ____________________________________________
___ Cancer
___ Asthma
Specify: __________
___ Arthritis
___ Cerebral Palsy
___ Diabetes
___ Epilepsy
___ Fainting Spells
___ Gynecological Problems
___ Head/Neck Injuries
___ Hearing Aid
___ Hearing Problems
___ Hemophilia
___ High Blood Pressure
___ Mobility
Specify: __________
___ Multiple Sclerosis
___ Muscular Dystrophy
___ Neurological Problems
___ Obesity
___ Under Psychiatric Care
___ Vision Problems
___ Other
Specify: ____________________________________________
Does the student have any on going health problems?
Please Specify:
Does the student take any medicine regularly?
No
Please Specify:
Does the student have any allergies or allergic reactions?
Please Specify:
IN CASE OF AN EMERGENCY PLEASE NOTIFY:
Parent/Guardian: (
)
Area Code
Other Relative:
(
Name/Relation
(
Home Phone #
No
Yes
Yes
No
)
Area Code
)
Area Code
Yes
Cell Phone #
(
Home Phone #
)
Area Code
Cell Phone #
IN CASE OF EMERGENCY WHICH REQUIRES IMMEDIATE ATTENTION, YOU’RE AUTHORIZED TO
TAKE WHAT EVER STEPS ARE NECESSARY TO ENSURE THE HEALTH AND SAFETY OF MY CHILD.
Parent/Guardian:
Name
Signature
9
Date
TRiO/Upward Bound Math & Science
College of the Sequoias
915 S. Mooney Blvd. - Visalia, CA 93277
Phone: (559) 737-5400
www.cos.edu
SECTION I:
I1.
TO BE SIGNED BY STUDENT
Student Pledge
PART I – REQUIREMENTS
I pledge to:
 Attend school on a regular basis, be attentive in class and make an effort to understand the material presented.
 Complete every assignment, take every test and participate in class discussion; if assignments are not
understood, I will ask my tutor or instructor for assistance.
 Enroll in college preparatory courses with counselor’s approval and keep the TRiO/UBMS Advising
Specialist informed of the courses I’m enrolled in.
 Attend all required TRiO/UBMS activities (i.e., After School Tutorial and Saturday Sessions) and avoid
scheduling doctor/dentist or other appointments which conflict with TRiO/UBMS activities; I will notify the
TRiO/UBMS office (559) 737-5400 if an emergency condition arises which prompts absence from After
School Tutorial or Saturday Sessions.
 To make up academic assignments if I am absent for a valid reason (i.e., illness or family emergency).
 Bring required books and assignments to After School Tutorials. If there is no specific assignment, I will
bring books to review or ask tutors to provide other materials to increase my academic skills.
 Behave appropriately during TRiO/UBMS activities and while being transported to and from activities.
PART II – GRADES
I pledge to maintain a 2.0 grade point average with no Ds and/or Fs, or I can expect the following:
 To be placed on academic probation and my parents and school will be contacted regarding my status.
 To meet with the Advising Specialist and develop a Plan of Action to systematically improve my grades.
 If my grades do not meet TRiO/UBMS requirements by the following grade period, I may be terminated from
TRiO/UBMS.
I understand that TRiO/UBMS is an opportunity for me to develop my potential and I fully intend to utilize that
opportunity. I understand that if I work with the program staff to enhance my talents and strengths and overcome
my weaknesses, I will succeed. I realize that my obligations to TRiO/UBMS have been determined and outlined
in this pledge for my benefit. I fully understand that it is a privilege to be in this program. My signature is a
commitment to the spirit of TRiO/UBMS: to respect human growth through learning self-improvement and
dedication.
Student:
Name
Signature
10
Date
TRiO/Upward Bound Math & Science
College of the Sequoias
915 S. Mooney Blvd. - Visalia, CA 93277
Phone: (559) 737-5400
www.cos.edu
Transporting Permit
I hereby authorize my child,
to attend the TRiO/UBMS After School Tutorial &
Saturday Sessions at the College of the Sequoias or other assigned sites. I understand that TRiO/UBMS will be
transporting students to & from their designated sites to attend Program sponsored activities.
PARENT/GUARDIAN TO COMPLETE EMERGENCY INFORMATION:
Name of student:
Parent/Guardian:
Home Phone #:
Work/Message Phone #:
CHECK OPTIONS 1 OR 2 TO INDICATE DESIRED ACTION IN THE EVENT OF AN EMERGENCY
( ) 1. In the event of an emergency, when a parent/guardian in unavailable, I hereby authorize a representative of
the Program to make such arrangements, as they consider necessary for my child to receive medical/hospital care,
including necessary transportation. Under such circumstances, I further authorize the physician named below to
undertake such care and treatment of my child as they consider necessary. In the event said physician is not
available at the time of the emergency, I authorize such care and treatment to be performed by any licensed
physician. THE UNDERSIGNED PARENT/GUARDIAN FULLY UNDERSTANDS THEY ARE
RESPONSIBLE TO PAY ALL COSTS INCURRED AS A RESULT OF THE FOREGOING.
Physician’s Name:
Medical Insurance (Kaiser, BlueCross, etc.):
Phone #:
Policy #:
( ) 2. I do not choose the above statement and desire the following actions to be taken:
DATE OF ACTIVITY/FIELDTRIP:
T.B.A.
TIME & DATE OF DEPARTURE:
T.B.A.
TIME & DATE OF RETURN:
T.B.A.
Staff attending activities will be employees of College of the Sequoias.
Waiver: California Law provides as follows: “All persons attending fieldtrip or excursion shall be deemed to
have waived all claims against the District or the State of California for injury, accident, illness or death occurring
during or by reason of the fieldtrip or excursion. (Education Code Section 35330) My signature on this form
shall constitute an informed and knowing waiver as required by law.”
My signature below authorizes my child to participate in the Upward Bound Math & Science Activities.
Parent/Guardian Signature:
Date:
If questions arise before, during & after event, please contact UBMS office at (559) 737-5400.
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