UPWARD BOUND 2015-2016
New Student Application
Federal TRiO Program
Funded by the U.S. Department of Education
The personal information you give to the Upward Bound program is kept on file for the federal government (US Department of Education). The
information is protected by the Privacy Act. No one may see the information unless they work with or for the Upward Bound project or are
specifically authorized to see the information. The information is necessary to determine if you are eligible to participate in the program and helps the
government to measure our success. The Department of Education has the authority to gather information to help make Upward Bound a better
program. Reasonable accommodations, including materials in an alternative format will be made for individuals with disabilities when a
minimum of five working days advance notice is given. For the general public, please contact the PCC information line at 520.206.4500.
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TRiO Upward Bound Program
Pima Community College – Desert Vista Campus
5901 South Calle Santa Cruz
Tucson, AZ 85709-6000
Phone: (520) 206-5073 Cell: (520) 269-9888 or (520) 269-9882
Fax: (520) 206-5206
Dear Parent/Guardian:
Your child has indicated an interest in participating with the TRiO Upward Bound program. This program is a
free college preparatory program for high school students funded by the U.S. Department of Education. Upward
Bound is designed to strengthen the academic skills of high school students and help them pursue
postsecondary degrees after high school graduation.
Year-round services provided by TRiO Upward Bound include:
 Academic advising from TRiO Upward Bound staff; After school tutorial services during the school year to
strengthen academic skills and prepare students for success at the college level
 A 6-week summer instructional component that is designed to simulate a college-going experience that
includes daily coursework in English, math, science, and foreign language as well as other related activities
such as field trips and special events
 Individual assistance with college admissions and financial aid application process during the school year
 Field trips to college campuses, career exploration and cultural enrichment activities
Upward Bound participants must meet the following criteria:
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Indicate an interest in attending college
Demonstrate academic need
Qualify as Low Income and/or Potential First Generation College Graduate (neither parent has
received a 4-year degree)
Commit to remain active in Upward Bound until high school graduation
Must be a U.S. citizen or a permanent resident.
Please complete this ENTIRE application and return to: Desert View HS Office located in room 3103,
Sunnyside HS Office located in room 302, Pima Community College, Desert Vista Campus Office located
in room A-127, or fax to (520) 206-5206. Applications will be considered complete when they include: program
application, two letters of recommendation, a copy of the first two pages of your most recent U.S. Federal
income taxes and the student’s most recent report card. Eligible applicants will be contacted to complete an
assessment test at Pima Community College once application is completed.
Thank you for your interest in the TRiO Upward Bound program. Please contact me at (520) 206-5073 or
dapacheco@pima.edu if you have any questions or need additional assistance.
Sincerely,
Daniel Pacheco
Project Director, TRiO Upward Bound
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Upward Bound Program Application
DIRECTIONS:
 Print clearly in ink.
 Be sure to answer all questions. (Applications missing ANY answer will NOT be considered)
 Remember your parent/guardian’s signature is required.
 Please submit your complete application directly to any Upward Bound-Desert Vista Campus staff member.
PART I - STUDENT APPLICANT INFORMATION
Date:
Name:
SSN# or Permanent Resident#:
Email Address:
High School Currently Attending:
Current Grade Level:
Mailing Address: Street and Apt. No.
City:
State:
Home Phone Number:
Student Cell Phone Number:
Date of Birth:
Zip:
Age:
Gender:
__________Male ___________Female
Citizenship:
Are you a U.S. Citizen?  YES  NO
If NO – Are you a Permanent Resident?  YES  NO
(If you are NOT a U.S. Citizen or Permanent Resident unfortunately you are NOT ELIGIBILE for the Upward Bound Program)
______________________
Ethnic Background:
African American or Black ____
Native American ____
Native Hawaiian/Pacific Islander ____
Hispanic/Latino/Mexican American ____ White ____
Asian ____
Other/more than one ethnicity ____
Who do you live with? (check all that apply)
Mother & Father ____
Father (Stepfather) ____
Mother (Stepmother) ____
Guardian ____
Other ____
What language is spoken at home? (check all that apply)
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English ____
Spanish ____
Other ______________________
Do you work or plan to work this school year and/or this summer?
Yes ____
No ____
If Yes, when? _____________________________________ Where? ________________________________________________
How many hours per week? ____________
Please list any extracurricular activities (sports, clubs, religious, etc.) you are involved in:
_____
_____
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Student Needs Assessment
Are you classified as a LEP (Limited English Proficiency)
student?  Yes
 No
Need help learning the English Language?  Yes  No
What is your current grade point average (gpa)?
(If you’re a 1st Quarter freshman please provide your 8th grade gpa)
What college or university do you plan to attend?
What do you plan on majoring in?
 Undecided
 Undecided
What kind of career or job would you like to have?
How did you find out about the TRiO Upward Bound Program?
 Undecided
What type of degree do you plan to obtain? (You may check more than one.)
 Undecided
High School Diploma ____
Vocational or Technical School Degree ____
Bachelors (4 year) Degree ____
Master’s Degree ____
Undecided____
Associates (2 year) Degree ____
Doctoral Degree ____
Please check all the following TRiO UB services and activities that you need or would be interested in receiving this year?
ACADEMIC SERVICES & ACTIVITIES: You may check more than one.
_____ Academic Advising and Report Card Checks
_____ Study & Test Taking Skills
_____ AIMS Test Preparation & Tutorials in: Math 
English 
Writing 
Science 
Other 
_____ Tutoring or Homework Assistance with the following core high school courses (You can check more than one):
 Math  English  Science  Foreign Language  Social Studies  Other ________________________
_____ College Preparatory Instruction and Assistance in Honors or A.P. Courses
_____ College Adjustment and Orientation Activities
_____ Early College Enrollment Program Information
_____ Other ___________________________________________________________________________________
COLLEGE ADMISSIONS & FINANCIAL AID SERVICES & ACTIVITIES: You may check more than one.
_____ College Awareness and Exploration
_____ College Field Trips
_____ Financial Aid Awareness and Scholarship Information
_____ College Entrance Exam (ACT/SAT) Information and Preparation
_____ College Admissions and Testing Fees
_____ Individualized Assistance with College Admissions & Financial Aid Application Process
_____ Other ___________________________________________________________________________________
OTHER SUPPORTIVE SERVICES & ACTIVITIES: You may check more than one.
_____ Financial Literacy
_____ Goal-Setting and/or Self-Esteem Building
_____ Leadership & Citizenship Skills
_____ Career Awareness and Exploration
_____ Career Field Trips
_____ Cultural Awareness
_____ Community Service Opportunities
_____ Other ___________________________________________________________________________________
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PART II – UB Parent Application (To Be Completed by Parent/Guardian):
Student’s Name:
Current School & Grade Level:
Mother’s/Guardian’s Name:
Father’s/Guardian’s Name:
Mother’s/Guardian’s Address:
Father’s/Guardian’s Address:
Mother’s/Guardian’s Home Phone Number:
Father’s/Guardian’s Home Phone Number:
Mother’s/Guardian’s Cell Phone Number:
Father’s/Guardian’s Cell Phone Number:
Mother’s /Guardian’s Work Number:
Father’s/Guardian’s Work Number:
1.
2.
Did the student’s MOTHER graduate from college with a Bachelors (4 year) degree?  NO
(within the United States)
Did the student’s FATHER graduate from college with a Bachelors (4 year) degree?  NO
(within the United States)
 YES
 YES
Number of people living in your household? _____
What is your household’s most recent Federal TAXABLE income level?
***Taxable income is less than adjusted income and is located on page 2 of most tax return forms.
IMPORTANT: Please attach a copy of the first two pages of your MOST RECENT U.S. Federal Income Tax Form in order
to verify annual taxable income along with a COPY of the students Social Security Card or Permanent Resident Card
for verification of residency.
LIABILITY, MEDIA AND SCHOOL/COLLEGE/UNIVERSITY RECORDS RELEASE
As parent or legal guardian, you remain fully responsible for any legal liability which may result from any personal actions taken by the
named student. I hereby consent to participation by my child in the TRiO Upward Bound application/assessment process scheduled
between September 1, 2015 through August 31, 2016. I understand that these events may take place away from the school or Pima
Community College grounds and that my child will be under the supervision of the designated PCC/Upward Bound employees on the
activity dates. In consideration of my child being allowed to participate in the TRiO Upward Bound Program, I agree on behalf of myself
and my child, to release Pima County Community College District, its employees, volunteers and agents, and any and all affiliated
organizations, their employees, agents and representatives (collectively "Releases") from any and all claims, which may be asserted
by me or my child, or on behalf of my child, arising from or relating to my child’s participation in an TRiO Upward Bound activity or field
trip. In the event this release on behalf of myself and/or my child is held to be invalid or unenforceable, I hereby agree to indemnify and
hold harmless “Releases” from any and all claims which may be asserted by me or my child, or on behalf of my child, arising from or
relating to my child’s participation in the TRiO Upward Bound Program. This release of indemnification does not apply to claims for
intentional misconduct or gross negligence. I authorize the use of my child’s name and picture for media purposes. I release Pima
Community College – Desert Vista TRiO Upward Bound Program from any liability related to the publicity involving my child. I grant
access to my student’s academic transcripts, grade reports, report cards, AIMS scores, and any other information and test results
necessary to complete the program’s grant objectives for up to 10 years after high school.
ALL OF THE INFORMATION ON THIS FORM IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
_____________________________________________
Parent’s/Guardian’s Signature
__________
Date
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PART III
PERSONAL ESSAY
The personal essay is an important part of the selection process. In a 250 word essay or two minute video of yourself
discuss at least ONE of the following topics (feel free to type your essay if you wish and attach additional pages if
necessary):
1) Your purpose in applying to the TRiO Upward Bound Program, what you believe you will gain from the experience, and
the contributions you can make to the program.
2) What events or persons in your background have influenced you in your educational and career goals?
3) Discuss a personal, local, national, or international issue that concerns you.
4) What are your dreams for the future?
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As part of the application process you must submit two recommendation forms. Please remove pages 7 and 8 of the
application and hand the Recommendation Forms to a teacher and/or counselor who know you the best. Please have
them return the completed Recommendation Form to you in a sealed envelope to submit with this application.
PART IV – RECOMMENDATION FORMS (To be completed by a Teacher/Counselor)
Teacher/Counselor Recommendation Form
Dear Teacher/Counselor:
Your student is applying for admission into the TRiO Upward Bound (UB) Program of the Pima Community College, Desert Vista
Campus. The TRiO Upward Bound is a college preparatory program for low income and/or first generation college students. Your
assessment of the student’s conduct, character and academic need for program services is an integral element in the admission
process. Return the completed Recommendation Form to the student in a sealed envelope to submit with his/her completed student
application. Should you have any questions or concerns, please feel free to contact the TRiO Upward Bound Program Office at 520206-5073. The time and effort you have taken to complete this form is sincerely appreciated. Thank you.
Student’s Name
Class/Course Subject _______________________________ Current Class/Course Grade
Please tell us if you feel the TRiO Upward Bound Program would be Highly Beneficial (HB), Moderately Beneficial (MB), or Not
Beneficial (NB) to your student in each of the following areas:
STUDENT CHARACTERISTICS
(HB)
(MB)
(NB)
CITIZENSHIP
PARTICIPATION
RESPECT FOR OTHERS
ABILITY TO FOLLOW INSTRUCTIONS
ABILITY TO COMPLETE ASSIGNED WORK ON TIME
STUDY SKILLS/HABITS
ANALYTICAL THINKING SKILLS
MATURITY/INTEGRITY
ATTENDANCE AND PUNCTUALITY
EAGER TO LEARN NEW THINGS/INITIATIVE
PARTICIPATION IN A 6-WEEK SUMMER ENRICHMENT PROGRAM
Overall, do you feel this student has an academic need for services by the TRiO Upward Bound Program? □Yes
□No
Please provide comments on motivation, behavior, personality, strengths or weaknesses that you feel are pertinent to the student’s
performance in Upward Bound. Additional comments may be written on the back.
_________
_______________
____________________________________________________________________________________________________
___________________________________________________________________________________________________________
_______
Recommender Printed Name & Title
Recommender Email Address
Recommender Signature
Date
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PART IV – RECOMMENDATION FORMS (To be completed by a Teacher/Counselor)
Teacher/Counselor Recommendation Form
Dear Teacher/Counselor:
Your student is applying for admission into the TRiO Upward Bound (UB) Program of the Pima Community College, Desert Vista
Campus. The TRiO Upward Bound is a college preparatory program for low income and/or first generation college students. Your
assessment of the student’s conduct, character and academic need for program services is an integral element in the admission
process. Return the completed Recommendation Form to the student in a sealed envelope to submit with his/her completed student
application. Should you have any questions or concerns, please feel free to contact the TRiO Upward Bound Program Office at 520206-5073. The time and effort you have taken to complete this form is sincerely appreciated. Thank you.
Student’s Name
Class/Course Subject _______________________________ Current Class/Course Grade
Please tell us if you feel the TRiO Upward Bound Program would be highly beneficial (HB), Moderately Beneficial (MB), or Not
Beneficial (NB) to your student in each of the following areas:
STUDENT CHARACTERISTICS
(HB)
(MB)
(NB)
CITIZENSHIP
PARTICIPATION
RESPECT FOR OTHERS
ABILITY TO FOLLOW INSTRUCTIONS
ABILITY TO COMPLETE ASSIGNED WORK ON TIME
STUDY SKILLS/HABITS
ANALYTICAL THINKING SKILLS
MATURITY/INTEGRITY
ATTENDANCE AND PUNCTUALITY
EAGER TO LEARN NEW THINGS/INITIATIVE
PARTICIPATION IN A 6-WEEK SUMMER ENRICHMENT PROGRAM
Overall, do you feel this student has an academic need for services by the TRiO Upward Bound Program? □Yes
□No
Please provide comments on motivation, behavior, personality, strengths or weaknesses that you feel are pertinent to the student’s
performance in Upward Bound. Additional comments may be written on the back.
_________
_______________
____________________________________________________________________________________________________
___________________________________________________________________________________________________________
_______
Recommender Printed Name & Title
Recommender Email Address
Recommender Signature
Date
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