T r i o O u t r e a c h P r o g r a m s

In order to determine eligiblity for the program, you must complete and submit a program application. All information you submit will be kept confidential. Please submit via email to your Program Coordinator (based on high school, see below). Once submitted, eligible students will be contacted for an interview. Also parents will be contacted and asked to submit a signed statement regarding income.

Student Intake Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Student Participation Agreement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Release Authorization Form(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Parent Income Statement (separate document)

PAGE 1

PAGE 2

PAGE 3

Academic Advising

Goal/Value Setting

College Advising

Weekly Tutoring

Career Planning

College Tours

Scholar Saturday Field Trips

Summer Program at UCSD

Financial Aid Application

ACT/SAT Preparation

Applying to Colleges

College Planning

• Scholarship Search and Workshops• Academic Development Workshops

UBMS Only:• Hands on Science Opportunity

• Science, Medical, & Engineering Lab Visits

TRIO Upward Bound Program & Upward Bound Math ScienceUniversity of California, San Diego – 9500 Gilman Drive, #0341La Jolla, CA 92093-0341 – 858.534.4252 http://trio.ucsd.edu

Must be a U.S. Citizen or Permanent resident

Show desire to attend college after high school Must be a student at one of our target schools

UCSD Upward Bound & Upward Bound Math Science Program

Upward Bound (UB) & Upward Bound Math Science (UBMS) are a college preparatory programs for low income, first generation high school students in selected schools across San Diego County. Our mission is to help students to identify college requirements and to enroll in the college or university of their choice. As a federal program, we help students to achieve all types of higher education goals. UB & UBMS students will receive ongoing academic support services during their high school years. UB & UBMS tracks high school graduation, college enrollment, FAFSA completion and college graduation. Admitted students will receive FREE pre-college services including:

UB / UBMS Student Eligiblity Requirements:

UB / UBMS APPLICATION:

Program Coordinator: Ulises Alarcon

Upward Bound ClassicSan Diego, Lincoln

e-mail: ualarcon@ucsd.edu cell: 858-245-9579

Program Coordinators: Brandy Torres & Juan Ugarte Upward Bound Classic

Chula Vista, Sweetwater - Brandy Torrese-mail: bytorres@ucsd.edu cell: 858-242-7839

Mar Vista, Southwest - Juan Ugartee-mail: jugarte@ucsd.edu cell: 858-226-8458

Program Coordinator: Marcus Thompson

Upward Bound Math Science Clairemont, Mission Bay, Hoover

e-mail: mwthompson@ucsd.edu cell: 858-242-7941

Program Coordinator: Arthur Tovar

Upward Bound Math Science Mount Miguel, Monte Vista

e-mail: atovar@ucsd.edu cell: 858-242-7840

Parent will also be asked to verify income via a Parent Income Statement.

Low income and/or first generation college

Target Schools: Chula Vista, Clairemont, Hoover, Lincoln, Mar Vista, Mission Bay, Monte Vista, Mount Miguel, San Diego (SciTech and Business & Leadership schools only), Serra, Southwest and Sweetwater

Please reach out for any questions or need to clarify any information about program services or program requirements

U P W A R D B O U N D / U P W A R D B O U N D M A T H S C I E N C E

Current High School: _____________________________________________

Student ID #:_____________________________

Application must be signed by both student and parent. Today’s Date:_____________________ (DD/MM/YYYY)

Name:______________________________________________________________________________________________________________ Last Name First Name Middle Name

Home Address:___________________________________________________________________________________________ Number & Street Name Apt .No City State Zip Code

Date of Birth:___________________(MM/DD/YYYY)

Student Email:___________________________________________________________________________________________

Home Phone #: Student Cell Phone #: ___________________________

Gender: Male Female

1) Do you identify yourself as Hispanic/Mexican/Latino? Yes No

3)2) Please list your race: American Indian / Alaskan Native Asian/Asian American Black/African/African American

Caucasian/White Native Hawaiian or Other Pacific Islander Two or more races

Are you a U.S. citizen?: Yes No – If NO, Please list the number on the student Alien/Permanent Resident Card Number :

(Page 1)

STUDENT INTAKE INFORMATION

Student Ethnicity Background

Student Residency / Citizenship

Emergency Contact Name:__________________________________________________________________________________

Cell Phone: Home Phone: ___________________________

Relationship to Student:

Emergency Contact Information

Parents’ Marital Status: Single Married Separated Divorced Widowed

Name:____________________________________________

Occupation:_______________________________________

Work Phone #:_____________________________________

Cell Phone #:______________________________________

Parent E-Mail:_____________________________________

Parent/Guardian Highest Education Level Attained (please check one):

High School (9-12) Elementary (K-8) Associate Degree Bachelor’s Degree or Beyond

Did a parent/guardian graduate from a university with a Bachelors degree? Yes No If yes, in what? ____________________________

Language spoken at home:___________________________

Name:____________________________________________

Occupation:_______________________________________

Work Phone #:_____________________________________

Cell Phone #:______________________________________

Parent E-Mail:_____________________________________

Parent/Guardian Highest Education Level Attained (please check one):

Elementary (K-8) Associate Degree

High School (9-12) Bachelor’s Degree or Beyond

Did a parent/guardian graduate from a university with a Bachelors degree? Yes No If yes, in what? ____________________________

Language spoken at home:___________________________

Parent / Guardian Information

Do you have Health Insurance ? Yes No

Policy or Medical ID #:

Name of Health Insurance:_______________________________________

Phone #: ( )___________________________

Medical Insurance Information

Current Grade Level: ___________________________

Relationship to Student: ___________________________ Relationship to Student: ______________________________

Okay to release student? Yes No

U P W A R D B O U N D / U P W A R D B O U N D M A T H S C I E N C E

Please CHECK OFF all the high school/college need that applies to you.

I want tutorial resources to improve my classes grades. I would like advise on time management, test taking strategies, and study skills. I need guidance on courses required for college admissions. I need help on choosing a college and career options that is a best fit for me. I need help in completing college admission (UC, CSU, Private and CC) and financial aid (FAFSA) application forms.I need information about SAT/ACT (college entrance exams). I need advice on financial aid (e.g. scholarships, Grants, FAFSA) and other resources to pay for college. My parents and I need more information on financial aid. I want financial literacy: how to use credit cards, how to open a checking account, how to manage college expenses, etc. I am interested in a math or science college major. I want information about math and science college degrees. I want TRIO Upward Bound or Upward Bound Math Science to help mewith:____________________________________________________________________________________________

Assessment of Student Needs

The information gathered below does not affect whether you are eligible. These are mandatory questions TRIO Programs must collect for each student who applies to the Upward Bound / Upward Bound Math Science Program.

Are you currently enrolled in or have you ever taken the following courses? AP Course IB Course None

Have you already completed (with D or better) two years of math beyond Algebra 1? Yes No

Do you have a cumulative GPA of 2.5 or higher (for current year)? Yes No

Have you already completed (with C or better) Algebra 1? Yes No

Are you currently enrolled in a dual enrollment program that will allow you to earn a high school diploma and a college degree? Yes No

The UC San Diego Upward Bound (UB) and Upward Bound Math Science (UBMS) programs are designed to assist students who truly need the academic, college and financial aid support services. We require student's full participation in activities. Students who are admitted will be provided personalized support each year of high school. As a federal program we have many program activities and are required to collect student records on academic progress. As a result, student participation is crucial to ensure that students are receiving the proper guidance and support and are on track to graduate high school and enroll in college. Students must participate in the academic support services each year of high school, until high school graduation. As a federal program, all services are free. Note: *During distrance constraints of COVID-19 pandemic, UB & UBMS program services will be modified (mostly offered online) College Advising (Weekly) After-School Tutoring Sessions (Twice a Week) Academic, College, Cultural and Life Skills - Activities and Field Trips (Monthly) Summer Programs - Academic Enrichment Courses (Summer)

________________________________________ ____________________________________ _____________________ STUDENT / PARTICIPANT’S PRINTED NAME STUDENT / PARTICIPANT’S SIGNATURE DATE

________________________________________ ____________________________________ _____________________ PARENT / GUARDIAN’S PRINTED NAME PARENT / GUARDIAN’S SIGNATURE DATE

STUDENT PARTICIPATION AGREEMENT

Yes No Do you participate in another program like Upward Bound or Educational Talent Search?

Are you taking or have taken a/an English as a Second Language (ESL/LES/ELL/ELD) classes? Yes No

Are you currently homeless? Yes No Are you a foster youth or ward of the court? Yes No

Do you have any disabilities? Yes No Are you currently involved with the juvenile justice system? Yes No

Other Information About Student

What are your plans after high school graduation? (check ONLY one below)

4 Year University/College Community College Vocational/Trade School Military/Only Work Undecided

What do you want study (college majors), or what is your career goal?_______________________________________________

Student Postsecondary Plans

Mandatory Questions

(Page 2)

U P W A R D B O U N D / U P W A R D B O U N D M A T H S C I E N C E

Application must signed by both student and parent. Today’s Date: _________ (MM/DD/YYYY)

Students Name: ___________________________________________________________________________________________Last Name Middle Name

High School:___________________________

First Name

Student ID #:____________________

AUTHORIZATION RELEASE FORM

In the event of an emergency illness, injury or accident, the person or persons signing below authorize UCSD TRIO OutreachPrograms to take all necessary steps to provide first aid and medical treatment to my son/daughter/ward. This includesauthorization for transportation to a hospital or medical facilities, including outside of the UCSD campus, to administernecessary medical care. I/we authorize the release of medical and treatment information to the UCSD TRIO OutreachPrograms personnel only for the limited purpose of assisting to admit students for emergency care, assisting to release students from emergency medical care and obtaining the medical bill associated with the emergency care. I/we further agree to use myson’s/daughter’s/ward's insurance coverage, including Medi-Cal before using UCSD’s medical coverage in paying medicalbills which may be incurred. I/we understand that balance not covered by insurance will be my/our responsibility to pay. I/we agree to release UCSD from all legal claims and from any liability except those claims and rights that arise from gross negligence or willful misconduct on the part of UCSD TRIO Outreach Programs’ personnel.

I/we have read the above information and agree to allow (Student Name): ____________________________________to participate in the UC San Diego TRIO Upward Bound & Upward Bound Math Science Program as well as in all excursionstaking place as of this date, based on the conditions indicated above.

Medical Release Form

________________________________________ ____________________________________ ____________________ STUDENT / PARTICIPANT’S PRINTED NAME STUDENT / PARTICIPANT’S SIGNATURE DATE

________________________________________ ____________________________________ ____________________ PARENT / GUARDIAN’S PRINTED NAME PARENT / GUARDIAN’S SIGNATURE DATE

PLEASE READ AND SIGN BELOW AND SUBMIT YOUR APPLICATION FOR REVIEW

We hereby certify that the information reported in this application packet is true, complete and accurate to the best of our knowledge. We understand that a false statement or misrepresentation will make the applicant ineligible for the UCSD TRIO Outreach Programs - Upward Bound / Upward Bound Math Science Program.

Media Release Form

The person or persons signing below permit the UC San Diego’s TRIO Outreach Programs representative (Upward Bound &Upward Bound Math Science Program) and/or the news media to photograph, videotape, audiotape, duplicate and transfer to any present or future agents. UCSD TRIO UB & UBMS and the news media may use the photographs, videotapes, andaudiotapes only as appropriate to promote UCSD TRIO Outreach Programs (Upward Bound & Upward Bound Math ScienceProgram), related college enrollment objectives and program activities. No compensation will be paid for this use.

The person or persons signing below give consent to UCSD TRIO Outreach Progams (Upward Bound and Upward Bound Math Science) to request and receive the minor student's academic records, this includes: high school enrollment, academic progress report, high school transcript, California state test scores, SAT or ACT exam scores, high school graduation verification and attendance reports, FAFASA completion, college applications and proof of college enrollment. Records are kept private in accordance with federal law will be used to determine program eligibility and document student's academic progress.

(Page 3)

Academic Records Release Statement

The person or persons signing below give consent for their student to be called out from class for academic advising, college information, SAT/ACT enrollment, college application and college enrollment support, college planning and FAFSA completion.