UPWAR
RD BOUN
ND – ENG
GLISH TEA
ACHER ASSSESSMEN
NT FORM
M (p. 1 of 2)
Upward Bound iss a FREE colle
ege preparattory program
m for first‐genneration and income‐qualified studentts from the selecct target high schools. The
e services of tthe Upward B
Bound Progra ms assist students in explloring collegee and career oppo
ortunities, pre
eparing them to enter and succeed in p
postsecondaryy education u
upon graduation from high
h school. e email or faxx both sides o
of this form tto: Please
UPWARD B
BOUND PROG
GRAMS UNIVERSITY
Y OF NEVADA
A, RENO Phon
ne (775) 784‐4
4978 Fax (7775) 784‐62544 [email protected] This form
m may also b
be completed
d online at ww
ww.unr.edu//upward‐bound/eligibilityy‐and‐applicaation Studeent Name (Prrint): _______
___________
____________
_____________________ Current Grad
de Level: _______________
_ School: ________
____________
___________
____________
__ How loong have you known the ap
pplicant? ______________
nselor/Teache
er Name (Prin
nt): ________
____________
_______________________
___________________________________
_ Coun
Coun
nselor/Teache
er Signature: ___________
___________
____________________________________ Date: _____________
_ Pleaase check the
e academic, ccareer, and pe
ersonal need
ds of this stud
dent (please sselect at least three):
 G
GPA: __________ < 2.5 (low G
GPA)  LLow achievemeent test scoress  LLow educational aspirations  LLow grade poinnt average  D
Disconnected y
youth (foster c
are, homeless, juveenile justice)  LLimited Englishh proficiency  D
Diagnosed learrning disabilityy  Lack o
of opportunity,, support and/or guidance to
o take challeng
ging college preparatiion courses  Lack o
of career goalss and/or need f for accurate infformation on c
careers  Lack o
of confidence, self‐esteem, a
and/or social skkills  Interest in careers inn Math and/or Science  Predominantly low‐ income comm
munity  Rural isolation  Other: __________________________________________ Pleasse evaluate the student’s current overrall performance by checkking one ratin
ng for each caategory: Attendance (include ttardiness):  excellent
e
 good  fair  pooor  inconsistent Behavior: Classrroom Attitude/B
 excellent
e
 good  fair  pooor  inconsistent Maturrity Level:  excellent
e
 good  fair  pooor  inconsistent Work Ethic:  excellent
e
 good  fair  pooor  inconsistent Motivvation:  excellent
e
 good  fair  pooor  inconsistent  excellent
e
 good  fair  pooor  inconsistent Poten
ntial to Achieve C
College Readine
ess: Based on my expe
erience with the applicant, my recomm
mendation to
o Upward Bou
und is as follo
ows:  Higghly Recommeend  Recommend  Recom
mmend w/Res ervation  Do Not Reccommend continued o
Assessment A
on page 2 11
UPWARD BOUN
ND – ENG
GLISH TEA
ACHER ASSSESSMEN
NT FORM
M (p. 2 off 2)
___________
____________
_ High Schoo
ol: _____________________________________ Applicant Name: ___________
Pleasse provide thrree reasons this student w
will benefit fro
om Upward B
Bound. _________________
_____________
____________
_____________
______________________________________________________________
_ _________________
_____________
____________
_____________
______________________________________________________________
_ _________________
_____________
____________
_____________
______________________________________________________________
_ In wh
hat academic areas does this student need assistancce? _________________
_____________
____________
_____________
______________________________________________________________
_ _________________
_____________
____________
_____________
______________________________________________________________
_ _________________
_____________
____________
_____________
______________________________________________________________
_ Pleasse describe th
he commitme
ent of the stud
dent and his//her family too academic su
uccess. _________________
_____________
____________
_____________
______________________________________________________________
_ _________________
_____________
____________
_____________
______________________________________________________________
_ _________________
_____________
____________
_____________
______________________________________________________________
_ COMMENTS OR ADDITIONAL INFO
ORMATION: _________________
_____________
____________
_____________
______________________________________________________________
_ _________________
_____________
____________
_____________
______________________________________________________________
_
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______________________________________________________________
_ _________________
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______________________________________________________________
_
_________________
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______________________________________________________________
_ 203 Edmun
nd J. Cain Halll/0062 Reno, NV 89557‐00062 Phon
ne (775) 784‐4
4978 Fax (7775) 784‐62544 12
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