Program Application 
Student Information:

Thank you for your interest in our Upward Bound program!  Please complete this application as thoroughly as possible. 

IMPORTANT: You cannot save and restart this application.  You may want to review the included items, take some time to make notes and gather the required documents, and then return to submit your application. 

If you have any questions, please call our office or contact a UB Staff member.

Liliana Rodriguez,  Program Coordinator Rodriquez_Liliana@sac.edu (714) 564-5423

 Veronica Hurtado, Director Hurtado_Veronica@sac.edu (714) 564-6796
Last Name *
First Name *
Middle Name
Date of Birth *
Permanent Address 1 *
City *
State *
Zip *
Cell Phone Number *
Check the box to accept text messages?
Student ID Number *
School Name *
Grade Level
School Email Address *
Personal Email
Please upload your most recent high school transcript *
Eligibility Criteria 
Citizenship Status: *
Is English your second language? *
Are you a First-Generation student? *
Do you confirm that you are NOT part of Santa Ana College (SAC) Academic Talent Search, California State University, Fullerton (CSUF) Upward Bound, or other related TRIO programs
Demographic Information:
Ethnicity *
Gender *
Preferred Gender Pronouns: *
Family Information 
Father's/ Guardians Name: *
Cell Phone Number *
Highest Level of education your father/guardian completed: *
Father’s/Guardians Email: *
Mother’s/Guardians Name: *
Cell Phone *
Highest Level of education your mother/guardian completed: *
Mother’s/Guardians Email *
Primary Language spoken at home *

Parent Financial Information

What was your family’s taxable income (not total) income from the last calendar year?

*Note: Taxable Income can be found on the federal income tax form.
 On IRS form 1040 see line 43
 On IRS form 1040A see line 27
 On IRS form 1040EZ see line 6

* See example below:
How many people TOTAL live in your household *
Please read the three options below and answer according to your parents taxable income. Taxable Income can be found on the federal income tax form. Put $0 on the ones that do not apply. 
1. My family filed a federal income tax return for the last calendar year, and my family’s taxable income from the last calendar year was *
2. My family did not file a federal income tax for the last calendar year, but my family’s total income from the last calendar year was *
3. My family had no taxable income during the last calendar year *
Do you qualify for either program? *

Autobiographical Question

Please respond to the following questions:
1. Introduce yourself. Include any hobbies, extra-curricular activities, or clubs you are involved with. *
2. What motivates you to go to college and describe your educational and career plans for the future? *
3. How are you doing academically in high school, and what do you think you can do to improve your grades? *
4. How would you benefit from the Upward Bound Program? *
5. Why should you be selected to participate in Upward Bound? *
Certification, Permission, and Consent

CERTIFICATION: 

I hereby give the Upward Bound staff permission to have access to report cards, high school transcripts, college/university transcripts and enrollment data, standardized test results, and other pertinent information. I understand that this permission will be in effect throughout my child’s participation in the Upward Bound program and six years after their high school graduation. To facilitate provision of program services, I grant consent for my child to occasionally be called out of class for advising by Upward Bound staff. Finally, I certify that all information provided in this application is accurate and true to the best of my knowledge.

In the event that my child is offered and accepts an invitation to participate in the Upward Bound program:

•I affirm that my child is in good health and able to participate in Upward Bound activities. I voluntarily assume the risk of any possible injury/illness or property damage associated with her/his participation in UB activities. If my child needs emergency medical treatment and her/his emergency contact cannot be reached, I consent to any medical treatment deemed advisable by any licensed physician and agree to be financially responsible for any costs incurred as a result of such treatment.

•I grant the college permission and the right to photograph my child and to place such photographs in Upward Bound publications, and/or social media for promotional purpose only. I understand and acknowledge that neither I nor my child will receive any monetary compensation for the use of her/his likeness; have the opportunity to inspect or approve any photograph prior to its use or release; or have any copyright interests in any photograph. The college agrees that if it selects a photograph of my child, that photograph will not be used for any purpose other than to promote the college and the Upward Bound program.

 

Sign and Submit:
Applicant Signature *
Signature Type: Simple    Start Over
Signature: (Type in your full name)
I agree to the terms included.
Parent Signature *
Signature Type: Simple    Start Over
Signature: (Type in your full name)
I agree to the terms included.