Print Form
FOR OFFICE USE ONLY
Accepted Date
Date Received
First Generation
Citizenship
Income
Age
Family Size
School / Grade
University of Houston - Downtown
One Main Street, Suite N-220
Houston, Texas 77002
UPWARD BOUND
APPLICATION FOR ADMISSION
To the Applicant and his / her Parent(s):
This application is our initial introduction to you and will play an important part in our consideration of
you as an Upward Bound student. It is essential that the entire application be completed before it is
returned. Write clearly and in pen. Do not hesitate to add information you feel is pertinent to your
application. INCOMPLETE APPLICATIONS will not be considered for admission.
1. Name
LAST NAME
3. Home Address
MIDDLE
NUMBER & STREET
4. Age
7. Sex:
FIRST
APT.
Female
CITY
6. Place of Birth
5. Birthdate
Male
2. Home Phone
2a. Msg. Phone
ZIP CODE
CITY, COUNTRY
8. Social Security #
9. Will you require any special accommodations or any other limitations?
If
YES
NO
yes, please explain
10. Have you applied to Upward Bound before?
YES
I
Date
f yes, where
11. Ethnic Background
12. Citizenship Status
Black
US Citizen
White
Non US Citizen
NO
Hispanic
Alien Reg. #
Date
Other
13. Name of school attending now
14. Current Grade
15. Name of school you will attend in the fall
16. Number of persons living in household
17. With whom do you live?
Please Specify
Mother
Father
Relative
Other:
18. List all languages spoken at home:
19. Have either of your parents graduated from college?
YES
NO
20. SELF RECOMMENDATION
Spend a considerable amount of time completing this section. We are interested in discovering how you
feel about yourself as well as looking at your ability to express yourself in writing. Be candid in your
responses.
How will you coordinate your extra curricular activities/academic programs, which also meet on
Saturdays, with your Upward Bound participation? (Remember UB is a Saturday school during the
academic year and attendance is mandatory).
21. ESSAY QUESTIONS
On a separate sheet of paper, write an essay of at least three paragraphs on one of the following subjects.
Place completed essay inside application.
1. Describe your neighborhood, mentioning how it looks, who lives there, what you like or dislike
about it.
2. What do you hope to gain from your Upward Bound experience and what would you contribute to
the UB program.
3. Tell us about a special circumstance which may have affected your performance in school and
how you handled it. (Illness, family problems, discouraged, peers, sports, etc.)
Signature
Date
FINANCIAL INFORMATION
(To be completed by parent or guardian)
The personal information you give on the Upward Bound application is protected by the Federal Privacy
Act. The information is required by the U.S. Department of Education to determine eligibility.
Additionally, the Department of Education has authority to gather information on all Upward Bound
participants to monitor their progress. No one may see any information unless they work with or for the
program or are specifically authorized to see the information. Individuals who violate the privacy act
shall be subject to a fine of not more than $1,000 or imprisoned no more than one year, or both, and shall
be removed from employment.
22. List ALL sources of parent(s)/legal guardian(s) monthly and yearly income.
Father or Male Guardian's Name
Social Security No.
Yearly income $
Source of income or place of employment
Occupation
Relationship to student if not natural father
Phone # at work
Mother or Female Guardian's Name
Social Security No.
Yearly income $
Source of income or place of employment
Occupation
Relationship to student if not natural mother
Phone # at work
Total family income for (previous yr.) $
Number of people supported by this income
Other sources of income: Please Check
Social Security
Welfare
Veteran's
Child Support
Alimony
Disability
Pension/Retirement
Unemployment
TOTAL OTHER INCOME PER MONTH $
Compensation
23.
EMERGENCY INFORMATION
Give the name, address and phone number of someone (a relative or a friend) who does not live
with you but can be contacted in the event of an emergency. A telephone number is mandatory!
NAME ADDRESS CITY/STATE
TELEPHONE NUMBER
CERTIFICATION:
ZIP
CODE
RELATIONSHIP OF THIS PERSON TO YOU
We certify that all information reported on this application is true, complete and
accurate to the best of our knowledge.
PARENT OR GUARDIAN SIGNATURE
DATE
For more information please go to -- http://www.uhd.edu/upward