Upward Bound Application for Admission

Part I: Student Information

Name(Required)

First Middle Last

Gender(Required)

Male

Female

Birthdate(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent Phone (Home/Cell)

Student Phone

Primary Email(Required)

Please enter the primary email account used by your parents/guardians.

Ethnicity(Required)

African American/Black

Hispanic/Latin

Asian-American

Native American

Caucasian/White

Asian

Other

Are you a citizen or a legal resident of the U.S.?(Required)

Yes

If you respond "No," you will be asked to provide your Alien Registration number.

Part II: Academic Information

School Attending in the Fall(Required)

LaGrange Senior High School

Lake Charles College Prep.

Washington-Marion High School

Current Grade Level(Required)

Current Overall GPA:(Required)

9th Grade – Please attach a copy of your current grades.

10th Grade and above – Please attach a copy of your transcript from the Counselor’s Office AND a copy of your current grades.

Submit copies of your grades and transcripts:

Drop files here or

Max. file size: 128 MB.

Counselor's Name(Required)

First Last

Counselor's Phone(Required)

Please select the classes you have completed so far:(Required)

Foreign Language

French I

French II

Spanish I

Spanish II

None

Have you passed the LEAP Test?(Required)

Yes

If you answered "Yes," please submit a copy of the test results.

Submit a copy of your LEAP Test results:

Max. file size: 128 MB.

Do you work after school?(Required)

Yes

If you answered "Yes" to working after school, please state the name of your employer:

Please list your extracurricular activities:

Please write a short paragraph on your goals/ambitions and why you want to be a participant in the Upward Bound program.

List the colleges you would like to attend:(Required)

Student's Signature(Required)

I hereby authorize the McNeese State University Upward Bound Program to have access to my permanent school records during the application process and throughout the period of my active participation in the program and tracking period.

Part III: Family Information

Father's/Guardian's Name

First Last

Highest level of education completed:

Grade School

High School

Junior College

Vocational School

College/University (4-year degree)

Mother's/Guardian's Name

First Last

Highest level of education completed:

Grade School

High School

Junior College

Vocational School

College/University (4-year degree)

Primary language spoken at home:(Required)

How many persons (TOTAL) reside in your home?(Required)

Include parents, children and any other relative.

Name of parent(s)/guardian with whom you live:

First Last

Part IV: Financial Information

To be completed by the parent/guardian.

The U.S. Department of Education requires that Upward Bound gather this data to determine student eligibility. The information that you provide will be available upon request to the U.S. Department of Education, McNeese State University, and federal and state auditors.

All agencies must keep your information confidential and protected in accordance with the Privacy Act of 1974. Misrepresentation of the truth may lead to a serious penalty or more. Failure to provide the necessary information and supporting documents will prohibit your child from being considered for admission.

Did you file a Federal Income Tax Return for last year?(Required)

Yes

If you answered "Yes," you will be asked submit a copy of the Federal 1040A form, page 1 and 2 only. W-2 forms and check stubs are not accepted.

If you DID NOT file a tax return for last year or you are a recipient of public assistance, please list the source of any and all income you received during the last tax year:

Self Employment

Social Security

AFDC

Unemployment Compensation

Disability

Other

You will be asked to submit more information on this income to complete the review of this application.

Parent's Authorization(Required)

I hereby authorize the McNeese State University Upward Bound program to have access to my child's permanent school records during the application process and throughout the period of his/her active participation in the program and tracking period.

Office of Student Services