SIMPSON UNIVERSITY UPWARD BOUND (SUub)

MT. SHASTA HIGH SCHOOL – SUub (Upward Bound Application)

STUDENT APPLICATION
Please print neatly in BLUE or BLACK ink. Applications can be turned in to SUub Advisor Jeanine in room 2 at Mt.
Shasta High School or to the Mt. Shasta High School office. To be considered, turn in a completed application, a
parent/guardian verification form, and two recommendation forms.
Student Information:

1. Legal Name: ___________________________________________________________________

2. Mailing Address:________________________________________________________________
(Number & Street or P.O. Box) (City, State) (Zip)

3. Home Phone: ____________________________Student’s Cell Phone:____________________

4. Parent’s Name: Parent’s Cell Phone:

5. Student’s Email Address:_________________________________ Gender: ___Male ___Female

6. Citizenship Status: ___ U.S. Citizen ___ Permanent Resident Birthdate: _________________

7. School I attend: __________________ Grade: ______ Year of High School Graduation:______

8. Are you Hispanic? ___ No ___ Yes

9. Ethnic Background (please check ALL that apply): 10. List languages spoken in the
__American Indian/Alaskan Native home? (besides English)
__Mexican-American, Mexican, Chicano, other Latino, Spanish-Origin ________________________
__Asian, Cambodian, Chinese, Filipino, Korean, Laotian, Vietnamese
__White, European-American, Italian, Irish 11. Do you participate in an ELL
__Black, African-American, African (English Language Learner) or
__Native Hawaiian or other Pacific Islander ESL (English as a 2nd language)
__Other program at school?
___ No ___ Yes
12. Are you a Foster youth?
___No ___ Yes

13. I currently live with (please check one):

14. Do you have a diagnosed learning disability? ___ No ___ Yes - If Yes, please list:

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 TO BE COMPLETED BY STUDENT
Tell Us About Yourself - Please answer all questions thoughtfully and thoroughly (print in ink)

1. What academic area(s) interest you in school? Why?________________________________________

_____________________________________________________________________________________

2. What do you enjoy doing during your free time?____________________________________________

3. What do you see as your academic strengths? What other strengths do you have?________________

_____________________________________________________________________________________

4. In what subject areas would you like to improve?___________________________________________

5. What Careers are your considering?______________________________________________________

6. What Colleges are you considering?______________________________________________________

What services do you need in order to prepare yourself for college?

__Tutoring in: _____________________________________

__ Information about the benefits of going to college and earning a degree.

__ Information on how to strengthen my study and test taking skills.

__Information about high school and college requirements.

__ Help preparing for college entrance exam.

__ Information on the college admissions process and help completing college applications.

__ Information on college costs and help completing financial aid application.

__ Assistance with the college enrollment process and transitioning to college.

Describe who you are. Include achievements, interests and challenges you have overcome. Why is going
to college important to you? Why do you want to join Upward Bound and what do you hope to get out
of it? (You may use additional paper if necessary.) This essay should be in your words – it should not be
proofread or edited by anyone but you.

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 TO BE COMPLETED BY STUDENT
PERSONAL STATEMENT/ESSAY – CONTINUED

By signing below, I certify that each response within this application is true and complete to the best of my knowledge.

Student signature_________________________________________________________________________________________

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 MT. SHASTA HIGH SCHOOL
STUDENT AGREEMENT

I UNDERSTAND THE PURPOSE OF THE SIMPSON UNIVERSITY UPWARD BOUND PROGRAM (SUub) IS TO PREPARE
PARTICIPANTS TO SUCCESSFULLY COMPLETE ANY PROGRAM OF POST-SECONDARY EDUCATION (COLLEGE).

I AGREE THAT IF I AM ACCEPTED INTO THE SIMPSON UNIVERSITY UPWARD BOUND PROGRAM I COMMIT TO:

1. STRIVE CONTINUALLY TO IMPROVE MY SCHOOL GRADES AND MAINTAIN AT LEAST A 2.5 GPA
2. PARTICIPATE IN ALL WEEKLY, ACADEMIC YEAR, AND SUMMER COMPONENTS OF THE PROGRAM
THROUGH THE COMPLETION OF MY HIGH SCHOOL EDUCATION, UNLESS PROPERLY EXCUSED BY
UPWARD BOUND STAFF. (Weekly activities may include: after-school events, field trips, lunch, etc.)
3. FOLLOW THE INSTRUCTIONS AND COMPLETE REQUIRED DOCUMENTATION WHILE PARTICIPATING IN
SIMPSON UNIVERSITY UPWARD BOUND ACTIVITIES AND TRAVELING ON OFFICIAL UPWARD BOUND
TRIPS. I WILL COMPLY WITH ALL THE RULES AND REGULATIONS OF THE SIMPSON UNIVERSITY
UPWARD BOUND PROGRAM; I AM AWARE THAT FAILURE TO COMPLY COULD RESULT IN DISMISSAL
FROM THE PROGRAM.
4. CONDUCT MYSELF IN A POSITIVE MANNER AND ADHERE TO SCHOOL RULES AND EXPECTATIONS.
5. COMMUNICATE WITH MY UPWARD BOUND ADVISOR ABOUT MY EDUCATIONAL AND PERSONAL
GOALS.
6. MEET WITH MY UPWARD BOUND ADVISOR BI-WEEKLY AND PROMPTLY RESPOND TO CALL SLIPS AND
OTHER COMMUNICATIONS FROM MY ADVISOR, INCLUDING EMAILS AND TEXTS.
7. PARTICIPATE IN AN UPWARD BOUND ELECTIVE CLASS WHEN AVAILABLE, IF POSSIBLE.
8. GRADUATE FROM HIGH SCHOOL.
9. MAKE EVERY ATTEMPT TO ENTER AND COMPLETE A POST-SECONDARY (COLLEGE) EDUCATIONAL
PROGRAM AFTER HIGH SCHOOL GRADUATION.
10. PROVIDE FOLLOW-UP INFORMATION TO THE SIMPSON UNIVERSITY UPWARD BOUND PROGRAM
CONCERNING MY SUCCESS IN OBTAINING A POST-SECONDARY (COLLEGE) DEGREE.

BY SIGNING BELOW, I CERTIFY THAT EACH RESPONSE WITHIN THIS AGREEMENT IS TRUE AND COMPLETE TO THE
BEST OF MY KNOWLEDGE. IT INDICATES THAT I HAVE READ, REVIEWED, AND UNDERSTAND THE INFORMATION
ABOVE.

Student Name (please print)__________________________________________________________

Student Signature:__________________________________________________________________

Parent Name(s): ____________________________________________________________________