Student Name (Last) (First) (Middle) Address (Number and Street) (City/State/Zip) (Home Telephone)

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1 Upward Bound Program APPLICATION FOR ADMISSION (to be completed by STUDENT, and PARENTS or LEGAL GUARDIANS) This application will not be processed without the following documents: 1. completed application 2. academic record - copy of student s transcript 3. copy of student s most recent report card 4. copy of student s standardized test scores (eg. OGT, OPT, etc.) 5. parent/guardian income verification Student Information Student Name (Home Telephone) Student Social Security No. Alternate Phone Gender Male Female Date of Birth Citizenship/Place of Birth Student Address Ethnicity (voluntary) White African-American Appalachian Latino/Hispanic Asian Native American Other (specify) Student Lives With: Mother Father Both Parents Guardian Other (Please Specify) School Information School Student Attends Current Grade Current Grade Point Average (GPA) Parent/Guardian Release Statement I (we), as the parent(s) or guardian(s) of (Full Name of Student) grant my (our) permission for my (our) child to be nominated as an Upward Bound participant in the College of Mount St. Joseph Upward Bound Program. I (we) grant permission for the complete release of current and future school records of my (our) child and related family information to the College of Mount St. Joseph Upward Bound Program. I (we) understand that this application does not guarantee that my (our) child will be selected to become an Upward Bound participant. I (we) certify that all of the information furnished by me (us) to the College of Mount St. Joseph Upward Bound Program is true and complete to the best of my (our) knowledge. I (we) promise to provide whatever appropriate information as requested. I (we) realize that any misrepresentation of false information on these forms will lead to a withdrawal of any offer for my (our) child to join the program, or to later disqualification of my (our) child as an Upward Bound participant from the College of Mount St. Joseph Upward Bound Program. Signature of Parent/Guardian Date Signature of Parent/Guardian Date

2 Parent/Guardian Information Father Telephone (Home) (Work) Address Occupation Employer Highest Grade Completed Years of College Attended Degree(s) received Mother Telephone (Home) (Work) Address Occupation Employer Highest Grade Completed Years of College Attended Degree(s) received Guardian Telephone (Home) (Work) Address Occupation Employer Highest Grade Completed Years of College Attended Degree(s) received Emergency Contact (person other than those listed above) (Relationship to Student) Telephone (Home) (Work) Address Additional Emergency Numbers Name Name Phone Phone

3 Additional Parent/Guardian Information What is your relationship to the applicant? Biological Parent Foster Parent Step-Parent Guardian (name) (name) What are your future educational plans for your child? To continue in Cincinnati Public School District Private, Parochial, Christian Move to other Educational Alternative Suburban Public School District Home School Education Other (describe) For Office Use Date Received School Current Grade Academic Need Eligibility Code Ineligible Selected Wait List Reviewed by Comments

4 Family Income and Support (Please remember to submit income verification with your child s application) Father $ Source(s) Mother $ Source(s) Guardian $ Source(s) Non-Taxable Income from Other Sources $ Source(s) (monthly/yearly) Total Number of Family Members living in the Household $ Source(s) $ Source(s) List the ages of all children living in the home under the age of 21 years Please Check All Support Services the Family Qualifies for or Currently Receives Free Lunch Reduced Lunch Public Housing Social Security Food Stamps Housing Assistance Veterans/Disabled Benefits AFDC (Aid to Families of Dependent Children) WIC (Women, Infants & Children) Other (Please Specify) STOP! DID YOU REMEMBER TO ATTACH A COPY OF YOUR CURRENT 1040, 1040A, 1040EZ OR E-FILE RETURN? YOUR APPLICATION WILL BE CONSIDERED INCOMPLETE AND WILL NOT BE PROCESSED IF YOU DO NOT SUBMIT A COPY OF YOUR CURRENT FEDERAL INCOME TAX RETURN OR OFFICIAL DOCUMENTATION OF YOUR NON-TAXABLE INCOME (Social Security Verification, WIC, ADC/AFDC etc.)

5 Student Questionnaire (To be completed by the student who is being considered for nomination as an Upward Bound participant.) The purpose of the Upward Bound Program is to generate in program participants the skills and motivation necessary to complete a program of secondary education in and enter and succeed in a program of post-secondary education (college). (Federal Regulations 34 CFR Section 645.1). Thus, students selected to participate in the Upward Bound Program will receive opportunities for supplemental academic instruction in the areas of Math, laboratory science, foreign language, composition and writing skills; college tours, workshops on college preparation and career exploration, as well cultural enrichment programming. Additionally, students who fully participate in all required monthly program activities will receive a monthly stipend. Please explain what such an opportunity would mean to you? (Please use additional paper if necessary) Have you considered attending college or another form of higher education after high school? yes no What is your career goal? Please identify the academic programming you are currently enrolled in: College Prep Technical General Other (specify) Extra Curricular Activities Please return this completed Application Form to the College of Mount St. Joseph Upward Bound Program; to your Guidance Counselor, or to the designated UB REPRESENTATIVE at the school your child attends. Upward Bound is a federally funded TRIO program administered by the U.S. Department of Education and the College of Upward Bound. Upward Bound receives ninety-five percent ($234, 624) of its annual funding from the U.S. Department of Education and approximately five percent of its funding from the College of Mount St. Joseph.

6 UPWARD BOUND PROGRAM 5701 DELHI ROAD, CINCINNATI, OHIO (513) FAX (513) TEACHER EVALUATION After completing all the relevant questions below, give this form to a teacher who has taught you in an academic subject (English, Math, Science, Social Studies). NAME Male Female ADDRESS CITY: Cincinnati, OH ZIP: 452 PHONE: ( ) SCHOOL YOU NOW ATTEND: GRADE: TO THE TEACHER The Upward Bound application finds candid evaluations helpful in choosing from among highly qualified candidates. Please remember to sign below before submitting directly to Upward Bound or returning form to student for submission. Teacher Name Subject Area: Signature Date: School Name: School Address Cincinnati, Ohio 452 Teacher s Phone: ( ) BACKGROUND INFORMATION How long have you know this student and in what context? Years Months Context: What are the first words that come to your mind to describe this student? In which grade level(s) was the student enrolled when you taught him/her? 8 th 9 th 10 th 11 th 12 th List the courses in which you have taught this student, including the level of course difficulty:

7 RATINGS: Compared to other students in his/her class year, how do you rate this student in terms of: No Basis Context Below Average Academic Achievement Intellectual Promise Quality of writing Creative, original thought Productive class discussion Respect accorded by faculty Discipline work habits Maturity Motivation Leadership Integrity Reaction to setbacks Concern for others Self- confidence Initiative, independence OVERALL Average Good (above average) Very Good (well above average) Excellent Outstanding EVALUATION: Please write whatever you think is important about this student, including a description of academic and personal characteristics, as demonstrated in your classroom/school. We welcome information that will help us to differentiate this student from others and the students overall success in being a part of the Upward Bound program. TEACHER EVALUATION 2/2