UPWARD BOUND APPLICATION 1 Dear Applicant: Thank you for your interest in joining the Upward Bound Program at the University of North Carolina at Chapel Hill! Upward Bound is a federally funded program which prepares high school students for a college education through a variety of free services to Upward Bound participants. Since 1966, our Program has provided the tools, resources and training needed to help students succeed. You may apply as early as the Spring Semester of 8 th grade. All applicants should meet the required minimum Grade Point Average (GPA) of 2.0 on a 4.0 scale. Please see our website for additional eligibility requirements. Applications are accepted on a rolling basis. This means applications are reviewed and decided upon once the application is complete. Our Upward Bound Program serves a limited number of students. Therefore, it is important that you complete your application as soon as possible. When space is not available, an applicant may be referred to our waitlist for later consideration. Below you will find instructions for completing the application process. Once your application is received, you will be notified of your application status. If you have any questions, please do not hesitate to contact our Office at 919-962-1281. We look forward to hearing from you! Sincerely, Mr. Jonathan Earnest, Director of TRiO Programs Application Instructions 1. Download this application to your computer and print a copy. 2. Write in your responses to the questions. Please write legibly to avoid errors in processing. 3. The following supplemental items are also required to complete the application process. Be sure to include the student s name on all documents. Signed copy of parent s 1040, 1040A, or 1040EZ Income Tax Return for the most recent year* Signed Certification and Release of Information Authorization Forms Recommendation form from an academic teacher Recommendation form from a guidance counselor Academic transcript, recent report card, and test scores from your guidance counselor 4. Once your application is complete, please return it to the Upward Bound Program as a scanned document via email at upwardbound@email.unc.edu, via fax at 919-962-4381, or via mail: Upward Bound, UNC Chapel Hill 385 Manning Drive, SASB South, Suite 2301 Campus Box 8010 Chapel Hill, NC 27599-8010 5. You will receive a confirmation via email once your materials are received. If you do not receive an email with one week of submission, please call our office at 919-962-1281. We recommend keeping a copy of all application materials in case resubmission is necessary. *Please block out social security numbers on any information submitted by email.
UPWARD BOUND APPLICATION 2 UPWARD BOUND APPLICATION I. Student Information Last Name First Name Middle Name Permanent/Home Address City State Zip Current/Local Address City State Zip Email Address You will receive confirmation of your application at this email address. This will be the primary address for contacting you during the application process. Home Phone Work Phone Date of Birth (mm/dd/yyyy) Cell Phone Gender Race/Ethnicity (please select all that apply): American Indian/Alaskan Native Asian Black or African American Hispanic or Latino Native Hawaiian or Pacific Islander White Other (Please Specify): How would you describe your home town population? (please select one) Rural (Less than 10,000) Medium (10,000 50,000) Urban (Greater than 50,000) II. Academic Information Current Year in School (please select one) Middle/High School 8 9 10 11 12 Please note that, due to the nature of our programming, priority is given to applicants in grades 8, 9, and 10; however applications are accepted for grades 11 and 12 as space permits. Name of Current/Future High School Expected Month/Year of Graduation (mm/yyyy)
UPWARD BOUND APPLICATION 3 III. Citizenship Are you a citizen of the United States? Yes No If you answered No to the above question, please answer the following: Are you a permanent resident of the United States? Yes No If applicable: Permanent Resident # Date Issued If you are not yet a permanent resident, are you in the U.S. for other than a temporary purpose with the intent of becoming a permanent resident? Yes No If you are in the process of becoming a permanent resident, please provide evidence from the Immigration and Naturalization Service of your intent to become a permanent resident. IV. Family Background How many people, including yourself, are currently living in your household? (Line 6d on Income Tax Forms 1040 and 1040A) Family annual taxable income (for last tax year): (Line 43 on Income Tax Form 1040, line 27 on Form 1040A) Has your mother, father, or guardian earned a Bachelor s Degree? Mother: Father: Guardian/Other (Specify relationship to you): Yes No Yes No Yes No Unknown/NA Unknown/NA Unknown/NA With whom have you regularly resided and for how long? Mother: Father: Guardian/Other (Specify relationship to you): How long? How long? How long? Briefly provide any additional information, if necessary, regarding your family/living situation (ie. homelessness, foster care, recent adoption, etc.):
UPWARD BOUND APPLICATION 4 V. Parent/Guardian Information 1. Last First Middle Lives with you Married Divorced Widowed Relationship to you Deceased Single Separated Unknown Address City State Zip Email Address Education Level: Home Phone Cell Phone No High School Some High School High School Grad/GED Associate s Degree Bachelor s Degree Advanced Degree Unknown (i.e. Master s, JD, MD, PhD, etc.) Name of College(s), if any Degree(s), if any Occupation and Employer Work Phone 2. Last First Middle Lives with you Married Divorced Widowed Relationship to you Deceased Single Separated Unknown Address City State Zip Email Address Education Level: Home Phone Cell Phone No High School Some High School High School Grad/GED Associate s Degree Bachelor s Degree Advanced Degree Unknown (i.e. Master s, JD, MD, PhD, etc.) Name of College(s), if any Degree(s), if any Occupation and Employer Work Phone
UPWARD BOUND APPLICATION 5 VI. 3. Last First Middle Lives with you Married Divorced Widowed Relationship to you Deceased Single Separated Unknown Address City State Zip Email Address Education Level: Home Phone Cell Phone No High School Some High School High School Grad/GED Associate s Degree Bachelor s Degree Advanced Degree Unknown (i.e. Master s, JD, MD, PhD, etc.) Name of College(s), if any Degree(s), if any Occupation and Employer Work Phone Emergency Contact Information (This is your next-of-kin or someone you feel comfortable making medical decisions on your behalf.) If your Primary Emergency Contact is the same as someone in Section V above, please indicate: Same as above #1 #2 #3 If your Primary Emergency Contact is not someone listed above, please provide their contact information below: Last First Middle Relationship to you Lives with you Address City State Zip Email Address Additional information, if necessary: _ Home Phone _ Cell Phone _
UPWARD BOUND APPLICATION 6 VII. High School Information Guidance Counselor Name List any extra-curricular activities in which you are presently engaged: Have you been suspended or had other disciplinary issues? If yes, please explain: Please be sure to ask a guidance counselor to send a copy of test scores, a recent report card and high school transcript. VIII. Interest Information How did you learn about Upward Bound? Have you ever applied to our program before? Yes No If yes, please indicate year applied: Have you participated in other pre-college access programs? Yes No If yes, please select all that apply: AVID (Advancement Via Individual Determination) Educational Talent Search GEAR UP SLI (Scholars Latino Initiative) HSALA (Health Sciences and Leadership Academy) Student U Other, please specify: IX. Personal Statement On the following page, please submit a personal statement. In your personal statement, please address the following questions and be sure to include information about your interests, plans, and ambitions. Specifically comment on your goals concerning your education and career plans after high school. What are your educational goals? What are your career plans and how to you plan to achieve them? Why do you wish to enroll in the Upward Bound Program?
UPWARD BOUND APPLICATION 7 Please provide your personal statement below: The University of North Carolina is committed to equality of educational opportunity. The University does not discriminate in offering access to its educational programs and activities on the basis of race, color, age, national origin, religion, creed, genetic information, disability, veteran s status, sexual orientation, gender identity or gender expression. The Equal Opportunity/ADA Office (100 E. Franklin Street, Unit 110, CB #9160, Chapel Hill, NC 27599-9160 or (919) 966-3576) has been designated to handle inquiries regarding the University s non-discrimination policies.
UPWARD BOUND APPLICATION 8 Carolina Higher Education Opportunity Programs The University of North Carolina at Chapel Hill PARENT/GUARDIAN CERTIFICATION I declare that the information provided in this application is complete and accurate to the best of my knowledge. I understand that, if selected, my child will be expected to regularly attend all Upward Bound Program activities including Saturday Enrichment Academy, the After School Scholastic Institute sessions, and summer programs and participate fully throughout high school until he/she graduates and enrolls in a college or university. Name of Parent/Guardian (please print) Signature of Parent/Guardian Date Privacy Statement: All information on this application will be held in strict confidence. This information is necessary to ensure that the applicant meets the criteria for admission to Upward Bound as established by the U.S. Department of Education. Information will only be shared with Upward Bound staff and for reporting purposes to the U.S. Department of Education.
UPWARD BOUND APPLICATION 9 Carolina Higher Education Opportunity Programs The University of North Carolina at Chapel Hill Release of Information Authorization (PLEASE PRINT LEGIBLY) Student s Name Birth date High School I hereby authorize the release of my student s high school and postsecondary academic records, including test data, report cards, and transcripts, to the Upward Bound Program at The University of North Carolina at Chapel Hill for the duration of his/her academic career, even if the student is no longer enrolled in the Upward Bound Program, with the understanding that this information will be used solely for the purpose of assessment, academic planning, and/or reporting. Name of Parent/Guardian (please print) Signature of Parent/Guardian Date
UPWARD BOUND APPLICATION 10 COUNSELOR RECOMMENDATION FORM Please complete this form and return to applicant in a sealed envelope marked Counselor Recommendation with standardized test scores, a recent report card, and a high school transcript. Thank you for your assistance in evaluating this applicant for the Upward Bound Program! STUDENT S NAME SCHOOL _ Please rate the applicant on the following factors, from 1 (low) to 5 (high), or mark N/S if you are not sure how to rate based on your interaction with the student: 1. Academic Skills/Performance 1 2 3 4 5 N/S 2. Potential for College Success 1 2 3 4 5 N/S 3. Motivation to attend college 1 2 3 4 5 N/S 4. Need for academic support 1 2 3 4 5 N/S 5. Need for career development 1 2 3 4 5 N/S 6. Need for social skills development 1 2 3 4 5 N/S 7. Use of academic resources 1 2 3 4 5 N/S 8. Overall attendance 1 2 3 4 5 N/S Please provide specific comments regarding the applicant s academic and personal strengths: Please provide specific comments regarding the areas in which the applicant needs to improve, or in which they are lacking support: In specific detail, please comment on the student s demonstrated need for the academic support in preparation for college provided by Upward Bound: Name of Counselor (please print) Signature of Counselor Date
UPWARD BOUND APPLICATION 11 TEACHER RECOMMENDATION FORM Please complete this form and return to applicant in a sealed envelope marked Teacher Recommendation. Thank you for your assistance in evaluating this applicant for the Upward Bound Program! STUDENT S NAME COURSE _ Please rate the applicant on the following factors, from 1 (low) to 5 (high), or mark N/S if you are not sure how to rate based on your interaction with the student: 1. Academic Skills 1 2 3 4 5 N/S 2. Motivation to learn 1 2 3 4 5 N/S 3. Self-discipline 1 2 3 4 5 N/S 4. Timely assignment completion 1 2 3 4 5 N/S 5. Preparation for tests 1 2 3 4 5 N/S 6. Performance on tests 1 2 3 4 5 N/S 7. Punctuality 1 2 3 4 5 N/S 8. Overall attendance 1 2 3 4 5 N/S Please provide specific comments regarding the applicant s academic and personal strengths: Please provide specific comments regarding the areas in which the applicant needs to improve, or in which they are lacking support: In specific detail, please comment on the student s demonstrated need for the academic support in preparation for college provided by Upward Bound: Name of Teacher (please print) Signature of Teacher Date