APPLICATION OF INTEREST Please Indicate Your Program of Interest: Upward Bound Upward Bound Math & Science

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1 APPLICATION OF INTEREST Please Indicate Your Program of Interest: Upward Bound Upward Bound Math & Science 645 Patriot Avenue, Martinsville, VA RETURN TO UPWARD BOUND FOLDER IN GUIDANCE OFFICE The Upward Bound (UB) and Upward Bound Math & Science (UBMS) Programs are sponsored by Patrick Henry Community College and funded by the U.S. Department of Education. In order to determine your initial eligibility for program participation, the following information is needed. Name: Date of Birth: First M.I. Last MM/DD/YR Mailing Address: Phone: Are you a U.S. citizen? YES NO School: Present Grade Level: Parent or Guardian Names: Does either parent have a Bachelor s (4-year) college degree? YES NO Did your parents file a 2015 Federal Income Tax Return? YES NO If yes, please list their TAXABLE income ( line 43 or 1040A - line 27): $ Total number of exemptions claimed on return (1040 or 1040A line 6d): If no, please list the source(s) and amount(s) of non-taxable household income: Source: Monthly Amount: $ Source: Monthly Amount: $ Please share why you are interested in participating in UB or UBMS Program at PHCC: 1

2 Please list other activities such as athletics and band that you are actively involved in during the academic school year and summer months: Regular attendance in program activities is crucial to benefit from UB or UBMS. Do you sincerely feel you will be able to meet the yearly 60 attendance requirement which includes weekly meetings, Saturday sessions once a month, and at least two six-week summer programs before high school graduation? YES NO In signing this application, I certify that the information given is correct to the best of my knowledge. It is to be used to determine, in part, my eligibility to participate in the Upward Bound/Upward Bound Math & Science Program at Patrick Henry Community College. If I am accepted as a participant, I agree to abide by the rules and regulations of the program. Applicant s Name (print) Signature Date The information contained in this application is for the use of the UB/UBMS staff only and will be held in the strictest confidence. Please acknowledge, by your signatures, that the information given is correct and complete to the best of your knowledge. Parent or Guardian Signature(s) Date **Please note that this is only an Application of Interest and does not guarantee admission to the Upward Bound or Upward Bound Math & Science program. If the student appears eligible for the UB or UBMS program at Patrick Henry Community College based on the information submitted on this form, an application packet will be mailed to the student. This will begin the actual application process. If you have any questions or concerns, please call our office at (276) or bsigmon@patrickhenry.edu. The faculty and staff of Patrick Henry Community College and the Upward Bound Program/Upward Bound Math & Science support the principles of equal education and employment opportunity without regard to race, gender, or handicap. 2

3 Please write a one-page response to one of the following questions. Be mindful of spelling and mechanics. You may use the line sheet attached or type and attach your response to this application. 1. We are honored that you are interested in becoming a UB or UBMS participant. Please write a one page response detailing your interest in pursuing college and how you want UB/UBMS program and advisors to assist you in achieving that goal. 2. Fast-forward ten years. Where do you see yourself? What goals have you accomplished? How did you achieve those goals? 3. Every person on the planet finds motivation/drive/energy to be successful in his or her life from different places. Think about what keeps you amped? Who supports you? What aspects of your personality make you successful? 3

4 UPWARD BOUND (UB) UB MATH & SCIENCE SCHOOL COUNSELOR FORM Student: School: Grade: Current GPA: Days absent during current year: Special programs: Which of the following statements best describes this student? Has strong academic ability and achieves up to potential. Has strong academic ability but does not achieve according to potential. Indicates academic weakness but has potential to benefit from additional instructional and tutorial assistance. Other (describe): Comments: I recommend this student for enrollment in the Upward Bound/Upward Bound Math & Science Program. I do not recommend this student for enrollment in the Upward Bound/Upward Bound Math & Science Program. Counselor Signature Date ***Please attach a transcript, current grades and standardized test score data. Thank you for your willingness to assist this student. Shanna Francisco-King, Director (276)

5 UPWARD BOUND (UB) UB MATH & SCIENCE (UBMS) TEACHER ASSESSMENT FORM (student s full name) is interested in participating in the Upward Bound/Upward Bound Math & Science Program at Patrick Henry Community College. The program is designed to assist students in preparing for postsecondary education. Your willingness to assist the student by completing this form will be appreciated. 1. How long have you known this applicant? 2. Please indicate your assessment of this applicant: Most of the time Some of the time Rarely Is attentive to instruction and directions. Completes assignments. Actively participates in class discussions. Requests individual help when needed. Has positive and respectful attitude towards others. 3. Is student academically capable of success in a college-prep high school curriculum? Yes No 4. Is student academically motivated? Yes No 5. Have you had any discipline problems with this student? Yes No Comments: 6. Do you think UB/UBMS would benefit this student? Yes No 7. I recommend this student for acceptance in the UB/UBMS Program: Yes No Signature: Date: School: Position: 5