Upward Bound Application - Alabama A&M University

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Personal Data 100% funded by the U.S. Department of Education RY 2012 – Application Alabama A&M University Upward Bound Program Student Application Name of Applicant: ________________________________________________________________________ Last First Middle Address: _________________________________________________________________________________ City: _________________________________________________ State: ______ Zip: _________________ Home Phone: ( ) _______________________ Cellular Phone: ( ) ________________________ Social Security #: ________ - _____ - _______ Date of Birth: _________________ Age: ______ Sex: Male Female Email: _________________________________________ Ethnic Status: (For reporting purposes only) Black or African American White Asian American Indian/Alaskan Native Hispanic or Latino Native Hawaiian or Other Pacific Islander Other ___________ Academic Needs: (check all that apply) Lack of opportunity, support, and/or guidance to take challenging college preparation courses Lack of confidence, self-esteem, and/or social skills Lack of career goals and/or need for accurate information on careers Grade Point Average below 2.5 Predominately Low-Income Community Low Educational Aspirations Limited proficiency in English Low Achievement Test Scores Rural Isolation Other___________________ Have you participated in any other TRiO Program? Yes No If yes, list the name and location of the TRiO program. ___________________________________________ Academic Data School (Current): ____________________________________________ Grade: 8 9 10 (Please Circle One) School Address: ___________________________________________________________________________ Street City State Zip School Principal: _______________________________ Counselor: _______________________________ What is your current GPA?________ Do you plan to attend postsecondary school? Yes No
Family Data Mother’s/Guardian’s Name________________________________ Social Security #:_____ - _____ - _____ Address__________________________________________________________________________________ Street City State Zip Date of Birth _______________ Age___________ Email : ___________________________________ Employer_____________________________________ Annual Salary or Income $ __________________ Work : ( ) __________________ Home : ( ) __________________ Cell : ( ) __________________ Father’s/Guardian’s Name________________________________ Social Security #:______ - ____ - _____ Address__________________________________________________________________________________ Street City State Zip Date of Birth______________ Age___________ Email : ___________________________________ Employer_____________________________________ Annual Salary or Income $ __________________ Work : ( ) __________________ Home : ( ) __________________ Cell : ( ) __________________ TOTAL FAMILY INCOME $ ___________________________________ With whom do you live? Father Mother Both Grandparents Guardian Orphan/Ward of the Court Other____________________ Total number of persons in household (self included): _______ Total number of family members in household dependent on income of parent(s)/guardian(s): ________ Does your parent(s)/guardian(s), with whom you live, have a four-year (bachelors) degree? Yes No Are you a United States Citizen? Yes No If no, are you a permanent resident? Yes No I, ____________________________________ authorize the personnel of Alabama A&M University (Name of Parent/Guardian) TRiO-Upward Bound Program to secure all data needed to determine my child’s eligibility for participation in the Program. I understand the goals, objectives and requirements of TRiO-Upward Bound and agree to support my child in fulfilling them. I also understand that if my son/daughter does not fulfill the required goals and objectives, he/she will be terminated from the Program. I certify that all of the information I have provided is factual and correct to the best of my knowledge. _______________________________________________ ________________________ Student Signature Date _______________________________________________ ________________________ Parent/Guardian Signature Date 100% funded by the U.S. Department of Education RY 2012 – Application
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Upward Bound Application - Alabama A&M University

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