1. Healthcare

Sonoma State University
Upward Bound Programs
APPLICATION CHECKLIST
Complete all four (4) pages of the application, which includes:
Student Information, Parent/Guardian Information, and Student Academic Information
Transcript and Other Academic Records Waiver (parent, please be sure to sign!)
Summary (parent and student, please be sure to sign!)
Six (6) Short Answer Questions
Personal Statement
Current Transcript
Include a copy of your current transcript.
State and CAHSEE (if applicable) Test Scores
Include a copy of your State and CAHSEE test scores.
Income Verification Form
Complete the enclosed Income Verification Form.
Two (2) completed Upward Bound Recommendation Forms:
Counselor Recommendation Form: To be completed by your counselor or school
personnel (assistant principal/principal).
o Note: Parents must sign the Academic Records Release Statement before the
form can be given to the counselor.
Teacher Recommendation Form: To be completed by your Math, Science, English, or
AVID teacher.
o Note: If you are applying to the Upward Bound Math & Science Program, it is
required that your Teacher Recommendation Form be from a Math or Science
teacher.
The Upward Bound Programs Application Deadline is Saturday, January 31, 2015.
If you have any questions, please call (707) 664 3273.
Upward Bound is a TRIO Program federally funded by the United States Department of Education.
THIS PAGE IS BLANK ON PURPOSE
OFFICE USE ONLY LI _____ FG _____ Risk _____
SONOMA STATE UNIVERSITY
UPWARD BOUND PROGRAMS – STUDENT APPLICATION
Pre College Programs 1801 E. Cotati Avenue, Bldg. 49 Rohnert Park, CA 94928 3609
Office: (707) 664 3273 Fax: (707) 664 2886 www.sonoma.edu/precollege
DIRECTIONS: In order for your application to the Upward Bound Programs to be processed, you MUST turn in the following items
by the deadline:
A completed application form which includes a
State and CAHSEE (if applicable) Test Scores
personal statement
The Income Verification Form
A full academic transcript
Two (2) completed Recommendation Forms
................................................................................................................................................................................................
APPLYING TO:
Upward Bound Sonoma County
Upward Bound North
PLEASE PRINT ALL INFORMATION IN INK.
Upward Bound Math & Science
Date: ___________________________
A. STUDENT INFORMATION
1. Name: _______________________________________________________________________________
(First)
2.
(Middle Initial)
(Last)
Mailing Address: _______________________________________________________________________
(Number & Street or P.O. Box)
(City, State)
(Zip)
3.
Home Phone Number: _____________________
5.
Student’s Email Address: ________________________________________________________________
6.
Date of Birth: ____________________________
8.
Do you have a diagnosed Learning Disability?
9.
Do you have special needs?
10. Citizenship Status:
No
U.S. Citizen
4. Student’s Cell Phone: _________________
7. Gender:
No
Male
Female
Yes, please list: __________________________
Yes, please list: ________________________________________
Permanent Resident
11. Ethnic Background (please check ALL that apply):
American Indian/Alaskan Native
Asian, Cambodian, Chinese, Filipino,
Korean, Laotian, Vietnamese
Black, African American, African
12. I currently live with (please check one):
Both Parents
13. Is English the primary language spoken at home?
Mexican American, Mexican, Chicano,
other Latino, Spanish Origin, Hispanic
White, European American, Italian, Irish
Native Hawaiian or other Pacific Islander
Other
Mother Only
Yes
Father Only
Guardian
Foster Parent
No
B. PARENT/GUARDIAN INFORMATION
1. Parent/Guardian 1’s Name: ____________________________ Cell/Work Phone: _______________
2.
Parent/Guardian 2’s Name: _____________________________ Cell/Work Phone: _______________
3.
Has your parent received a Bachelor of Arts or a Bachelor of Science Degree within the United States?
Parent/Guardian 1: Yes
No
Parent/Guardian 2: Yes
No
C. STUDENT ACADEMIC INFORMATION
1. School I currently attend: ________________________ Grade:
2.
Are you currently enrolled in the Academic Talent Search (ATS)?
8th
Yes
9th (Not accepting 10th – 12th graders)
No
Student Name: _______________________________________________________________________________
(First)
(Last)
TRANSCRIPT AND OTHER ACADEMIC RECORDS WAIVER
Transcript and Other Academic Records Waiver
I hereby authorize my student’s school(s) to provide Sonoma State University’s Upward Bound Program
access to copies of my student’s academic records for the duration of the program and through completion
of post secondary education. I understand that these records will be kept confidential and will be used
strictly to follow student’s educational progress or to determine when extra scholastic services are needed
on his/her behalf.
Parent/Guardian Signature: _____________________________________
Date: _________________
SUMMARY
Parent/Guardian
Before my student is accepted into the Upward Bound Program, I agree to submit my current year’s income
tax or other income verification.
I certify that all the information on this application is complete and accurate to the best of my knowledge.
Parent/Guardian Signature: _____________________________________
Date: _________________
TELL US ABOUT YOURSELF
Please print in ink.
Please answer all questions thoughtfully and thoroughly.
1. I am considering the following careers: _____________________________________________________
2. I am considering the following colleges/universities: __________________________________________
3. Why do you want to participate in the Upward Bound Program?
_____________________________________________________________________________________
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4. What do you feel are your strengths and weaknesses, both in and out of school?
_____________________________________________________________________________________
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5. What academic area(s) are you interested in studying and why?
_____________________________________________________________________________________
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6. What do you enjoy doing during your free time?
_____________________________________________________________________________________
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PERSONAL STATEMENT
All students have a background or story that is central to their identity. Please share your story. You may include
information about your current and past achievements, activities, or challenges that you have overcome.
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1801 E. Cotati Avenue, Bldg. 49, Rohnert Park, CA 94928 3609
Phone: (707) 664 3273
Fax: (707) 664 2886
SONOMA STATE UNIVERSITY
UPWARD BOUND PROGRAMS
INCOME VERIFICATION FORM
Student’s Name: __________________________________________________ Program applying to: ___________
I, __________________________________, am the parent/guardian financially responsible for the applicant.
(Parent’s Name)
Please fill out Box A or Box B, depending on your situation.
A
If you filed a 1040 or 1040A for 2013:
1040 Form – Enter amount from Line 43
1040A Form – Enter amount from Line 27
$ _________________
$ _________________
Total number of exemptions claimed (Line 6d):
B
____
If you did not file a 1040 or 1040A for 2013:
List your estimated income
I supported
$ _________________
____ persons (including self and dependents) in the household during this period.
Under penalties of perjury, I declare that I have examined this form and to the best of my knowledge and belief, the
information is true, correct, and complete.
___________________________________________
Parent/Guardian Signature
_________________________
Date
___________________________________________
Student’s Social Security Number
1801 E. Cotati Avenue, Bldg. 49, Rohnert Park, CA 94928 3609
Teléfono: (707) 664 3273
Fax: (707) 664 2886
UNIVERSIDAD ESTATAL DE SONOMA
PROGRAMAS UPWARD BOUND
FORMA DE VERIFICACIÓN DE IMPUESTOS
Nombre del estudiante: _______________________________ Programa para el cual está solicitando: ________
Yo, ________________________________, soy padre/madre/guardián financieramente responsable del solicitante.
(Nombre de padre/madre)
Por favor llene la sección A ó B, dependiendo en su situación.
A
Si usted presentó una declaración de impuestos 1040 ó 1040A para el 2013:
Forma 1040 – Anote la cantidad de la Línea 43
Forma 1040A – Anote la cantidad de la Línea 27
$ _________________
$ _________________
Número total de dependientes reclamados (Línea 6d): ____
B
Si usted no presentó una declaración de impuestos 1040 ó 1040A para el 2013:
Indique su ingreso estimado
Yo mantuve a
____
$ _________________
personas (yo mismo(a) y dependientes) en mi hogar durante este tiempo.
Bajo penas de perjurio (jurar en falso,) declaro que he examinado esta forma y a lo mejor de mi conocimiento y
creencia, toda la información es verdadera, correcta, y completa.
___________________________________________
Firma de Padre/Guardián
_________________________
Fecha
___________________________________________
Número de Seguro Social del Estudiante
SONOMA STATE UNIVERSITY
UPWARD BOUND PROGRAMS
COUNSELOR RECOMMENDATION FORM
Student’s Name: ____________________________________________ School: ____________________ Grade: ______
TO THE STUDENT:
Before you submit this form to your counselor, your parent must sign the Transcript and Other Academic Records
Waiver below.
TRANSCRIPT AND OTHER ACADEMIC RECORDS WAIVER
I hereby authorize my student’s school to provide Sonoma State University’s Upward Bound Program copies of my
student’s academic records during the application process.
Parent/Guardian Signature: _____________________________________
Date: _________________
TO THE COUNSELOR:
Upward Bound is designed to assist students in preparing for and enrolling in the four year college/university of
their choice. Students who show potential, but need motivation and/or academic assistance in order to
succeed in college, may be nominated.
This Recommendation Form is very important in the evaluation and selection of students.
Please be as specific as possible in your remarks.
Recommendation Forms can be returned to the student or directly to our office.
Deadline: January 31, 2015
Recommender’s Name: ______________________________________________________________________________
Phone: _____________________ Email Address: _________________________________________________________
1. How long have you known the applicant? _________________________________________________________
2. State Test Scores
Please attach all State test scores available for the student.
Attached
Student did not test last year
3. Is the student classified as LEP (Limited English Proficiency) by the school?
4. School Attendance:
Excellent
Good
Fair
Yes
No
Poor
5. Does the student have any behavior issues that you are aware of?
___________________________________________________________________________________________
___________________________________________________________________________________________
Based on your knowledge of the applicant, please answer the following questions. Write “unknown” if not known.
6. What qualities best describe the applicant?
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
7. Upward Bound Programs is a huge commitment, in terms of both time and academic dedication. Are you aware of
any current circumstances or problems that may affect the applicant’s commitment and/or performance in the
Program (e.g., family responsibilities, educational preparation, health or emotional aspects, etc.)?
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
8. What is your assessment of the student’s potential and motivation to succeed? What is your evaluation of the
applicant’s capability for undertaking college preparatory high school work?
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
9. Recommendation level for this student to be admitted to the Upward Bound Program:
Strongly Recommend
Recommend
Recommend with Reservation
Do not Recommend
Signature: ________________________________________________________ Date: ____________________________
Please return to the student or directly to our office:
Sonoma State University
Upward Bound Programs
1801 E. Cotati Avenue, Bldg. 49
Rohnert Park, CA 94928 3609
Phone: (707) 664 3273 Fax: (707) 664 2886
SONOMA STATE UNIVERSITY
UPWARD BOUND PROGRAMS
TEACHER RECOMMENDATION FORM
Student’s Name: ____________________________________________ School: ____________________ Grade: ______
TO THE STUDENT:
You will need to have this form completed by a Math, Science, English, or AVID teacher. If you are applying to the
Upward Bound Math & Science Program, your Teacher Recommendation Form must be completed by a Math or
Science teacher.
TO THE RECOMMENDER:
Upward Bound is designed to assist students in preparing for and enrolling in the four year college/university of
their choice. Students who show potential, but need motivation and/or academic assistance in order to
succeed in college, may be nominated.
This Recommendation Form is very important in the evaluation and selection of students.
Please be as specific as possible in your remarks.
Recommendation Forms can be returned to the student or directly to our office.
Application Deadline: January 31, 2015
Recommender’s Name: ____________________________________________
Math Teacher
Science Teacher
Phone: _______________ Email Address: _____________________________
English Teacher
AVID Teacher
1. How long have you known the applicant? _________________________________________________________
Under what circumstances? ____________________________________________________________________
2. Based on your knowledge of the applicant, please rate his/her academic skills or performance:
Outstanding
Above Average
Average
Below Average
N/A
a) Academic Achievement/Grades
b) Writing Skills
c) Reading Skills
d) Math Skills
3. Based on your knowledge of the applicant, please rate his/her characteristics, motivation, and potential:
Strongly Agree
a) Has positive self image
b) Demonstrates leadership
capability
c) Self starter, has intellectual
curiosity
d) Is highly motivated
e) Handles frustrating or
disappointing experiences well
f) Has potential for academic
growth
Agree
Slightly Agree
Disagree
N/A
4. What qualities best describe the applicant?
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
5. Upward Bound Programs is a huge commitment, in terms of both time and academic dedication. Are you aware of
any current circumstances or problems that may affect the applicant’s commitment and/or performance in the
Program (e.g., family responsibilities, educational preparation, health or emotional aspects, etc.)?
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
6. What is your assessment of the student’s potential and motivation to succeed? What is your evaluation of the
applicant’s capability for undertaking college preparatory high school work?
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
7. School/Class Attendance:
Excellent
Good
Fair
Poor
8. Recommendation level for this student to be admitted to the Upward Bound Program:
Strongly Recommend
Recommend
Recommend with Reservation
Do not Recommend
Signature: ________________________________________________________ Date: ____________________________
Please return to the student or directly to our office:
Sonoma State University
Upward Bound Programs
1801 E. Cotati Avenue, Bldg. 49
Rohnert Park, CA 94928 3609
Phone: (707) 664 3273 Fax: (707) 664 2886