Western Michigan University Upward Bound Van Buren New Student Application Federal TRiO Program Funded by the U.S. Department of Education
Document Check list Please be advised. In order to be considered as a candidate for the Upward Bound Program the following information must be attached to Application Packet upon submission. Failure to comply will result in denial of application. Tax forms/income Verification Forms/Government Assistance Forms/Proof of Income Most Recent Report Card OR Recent Transcript MEAP/MME/M-STEP Scores Teacher/Counselor Recommendation #1 Name: Teacher/Counselor Recommendation #2 Name: Release Forms Student Personal Essay ***It is preferred that you type your essay*** The 300 words or more personal essay is an important part of the selection process. Please discuss ONE of the following topics: 1) What are some events or who are some people that have influenced you in your educational and professional aspirations? 2) What is your purpose in applying to Upward Bound Program? What do you believe you will gain from the experience, and what contributions can you make to the program? 3) What is your most impressive accomplishment and how it has impacted you. ***Essay guidelines: Times New Roman font, size 12 font and Double space *** Western Michigan University Office of Pre-College Programming Upward Bound-Van Buren Program 2211 Ellsworth Hall Kalamazoo MI 49008-5233 Phone: (269) 387-3377 Fax: (269) 387-3390 2 P a g e - g e 1 1. 1 7
Release of School Records Western Michigan University Upward Bound Program Dear, High school administrator/office staff and Counselor, As the parent/legal guardian of this student, I give my permission for him/her to participate in the Upward Bound program. I authorize the Upward Bound Program of Western Michigan University to access and/or receive copies of my student academic transcripts, grade reports, report cards, Standardized test scores and any other academic information necessary to apply, enroll, and complete the program. Please send a copy of my student s Current transcript Scores for standardized achievement, diagnostic tests/assessments, (MME) (M-STEP) (ACT) (SAT) Student Behavior Reports (If applicable) Academic Success Plans (IEP, 504, Specialized Education) Other academic information: Parent/Guardian name (please print): Parent/Guardian signature: Date: Phone Number: Dear High school administrator/office staff and Counselor, I hereby consent for the Upward Bound Van Buren Program to access my school records and to collaborate with school personnel on my behalf. Student name (please print): Student signature: Date: Phone Number: Contact Information Western Michigan University Office of Pre-College Programming Upward Bound-Van Buren Program 2211 Ellsworth Hall Kalamazoo, MI 49008-5233 Fax: 269-387-3390 Email: Keenan.a.king@wmich.edu 3 P a g e - g e 1 1. 1 7
Please note that all applications are accepted for review regardless of race, color, national origin, religion, gender or disability (U.S. Dept. of Education -GEPA Section 427). Upward Bound Van Buren Program Student Application (To Be Completed by Student) DIRECTIONS/TIPS: FILL OUT EVERYTHING COMPLETELY. Print clearly in ink. Be sure to answer all questions. Parent/guardian s signatures are required. This program is completely FREE for those qualify. This is a United States of America, federally funded, Department of Education program. No information will be shared. If you are unsure about this application or any of its contents, contact Gustavo Echavarria at 269-993-7871 Completed applications can be returned to the main office at your school or emailed to gustavo.echavarria@wmich.edu Date: Social Security#: PART I - STUDENT APPLICANT INFORMATION Name: Parent Email Address: School Currently Attending: Current Grade Level: Mailing Address: Street and Apt. No. City State Zip Home Phone Number: Cell Phone Number: Date of Birth: Age: Gender: Male Female Citizenship: Are you a U.S. Citizen? YES NO If NO Are you a Permanent Resident? YES NO r: Ethnic Background: African American or Black American Indian Asian/Pacific Islander Hispanic/Latino White More than one race (Please check all that apply) Other 4 P a g e - g e 1 1. 1 7
Who do you live with? Mother & Father Father Mother Guardian Other Name of Guardian if you do not live with one of your parents: What language is spoken at home? English Spanish Other: What is your favorite school subjects? What grades do you usually get in school? What college or university do you plan to attend? What do you plan to major in or study in college? What kind of career or job would you like to have? How did you find out about Upward Bound? What type of degree do you plan to obtain? You can check more than one. Vocational or Technical School Degree (Certificate program, 1-3 years) Associate Degree (2-years) Bachelor s Degree (4-year) Master s Degree (5-8 years) Doctoral Degree (6-12 years) List any extracurricular activities are you involved in? 5 P a g e - g e 1 1. 1 7
Dear Parent/Legal Guardian: Parent Application (To Be Completed by Parent/Legal Guardian) Your child has expressed an interest in the TRiO Upward Bound Van Buren Program at Western Michigan University. Upward Bound Van Buren is a free college preparatory program for high school students funded by the U.S. Department of Education and sponsored locally by Western Michigan University. Upward Bound Van Buren is specifically designed to strengthen the academic skills of eligible high school students to excel academically and pursue postsecondary degrees after high school graduation. Year-round services provided by Upward Bound Van Buren include: Tutorial services will be provided during the school year to strengthen academic skills and prepare student for success at the college level. A 6-week summer instructional component that is designed to simulate a college-going experience that includes daily coursework in math and science as well as other related activities such as field trips and special events. Academic advising from Upward Bound Van Buren staff and individual assistance with the college admissions and financial aid application process during the academic school year. In order to comply with federal regulations, all Upward Bound Van Buren participants must meet the following criteria: Indicate an interest in attending college; Demonstrate academic need Qualify as Income Eligible, Potential First Generation College Graduate (neither parent has received a 4-year degree), or defined as At-Risk (based on Federal definitions) Commit to remain active in Upward Bound Van Buren until high school graduation Thank you for your interest in the Upward Bound Van Buren Program. Please call Gustavo Echavarria Coordinator for Upward Bound Van Buren at (269) 993-7871 if you have any questions or need additional assistance. Sincerely, Director, Upward Bound The Family Educational Rights and Privacy Act (FERPA), 20 U.S.C. 1232g, are respectively federal and state laws providing for the review and disclosure of student educational records. The University and Outreach Programs-TRIO and GEAR UP will not permit access to or the release of personally identifiable information contained in student educational records to any party without the written consent of the student, except as authorized by FERPA. 6 P a g e - g e 1 1. 1 7
Student s Name: Current School & Grade Level: Mother s Name: Father s Name: Mother s Address: Father s Address: Mother s Home Phone Number: Father s Home Phone Number: Mother s Cell Phone Number: Father s Cell Phone Number: Mother s Work Number: Father s Work Number: Has either parent/guardian received a 4-year degree from a college or university upon completion of this application? Yes No I certify that the information provided on this form is true and complete to the best of my knowledge. Parent/Guardian s Signature Date Income Information: For purposes of documentation, please provide a copy of your most recent Federal Income Tax Return. Specifically, the W-1040. Make sure that it contains the names of your dependents and the Taxable Income for the current year. If you have not yet completed your tax return, please bring in a copy to the main office of your students high school. Number of Exemptions Including Yourself (Total number in your economic household): Did you, or are you planning to file a federal income tax return? Yes No If no, when was the last year you filed? IRS FORM 1040 Adjusted Gross income $ If you did not file a tax return. You will be required to provide another source of income verification before this application can be processed. PLEASE ASWER ALL THE QUESTIONS BELOW. Does your family receive benefits/assistance from any of the following sources? Yes No If yes, provide a copy of the of the award letter(s) for verification of assistance. *Must include the Student s name* Temporary Aid to Needy Families (TANF) Social Security Food Assistance Retirement Benefits Disability Veterans Benefits Other: The Family Educational Rights and Privacy Act (FERPA), 20 U.S.C. 1232g, are respectively federal and state laws providing for the review and disclosure of student educational records. The University and Outreach Programs-TRIO and GEAR UP will not permit access to or the release of personally identifiable information contained in student educational records to any party without the written consent of the student, except as authorized by FERPA. 7 P a g e - g e 1 1. 1 7
RECOMMENDATION FORMS (To be completed by a Teacher, Counselor, or school staff member) Dear Teacher/Counselor: The student listed below is applying for admission into the TRiO Upward Bound Van Buren Program at Western Michigan University. Your assessment of the student s conduct, character and academic need for program services is an integral element in the admission process. Please give us your honest assessment of this student s desire and ability to learn. Please deliver the completed Recommendation Form to the front office at your high school s or your WMU Upward Bound Van Buren representative. Should you have any questions or concerns, please contact Gustavo Echavarria Upward Bound Van Buren Coordinator at 269-993-7871. The time and effort you have taken to complete this form is sincerely appreciated. Student s Name: Class/Course Subject: Current Class/Course Grade: Grade Level: School: Please place an "x" in the appropriate column for each characteristic listed below: STUDENT CHARACTERISTICS EXCELLENT AVERAGE FAIR POOR CONDUCT IN CLASS WILLINGLY PARTICIPATES IN CLASS RESPECTS OTHERS AND THEIR PROPERTY ABILITY TO FOLLOW INSTRUCTIONS COMPLETES ASSIGNED WORK ON TIME STUDY SKILLS/HABITS ANALYTICAL THINKING SKILLS MATURITY/INTEGRITY PUNCTUALITY EAGER TO LEARN NEW THINGS/INIATIVE DEMONSTRATES MOTIVATION TO COMPLETE A 6-WEEK SUMMER PROGRAM Please provide comments on motivation, behavior, personality, strengths or weaknesses that you feel are pertinent to the student s performance in Upward Bound. You may attach additional comments to this form. Teacher s Printed Name & Title School Telephone Number Teacher s Signature Date The Family Educational Rights and Privacy Act (FERPA), 20 U.S.C. 1232g, are respectively federal and state laws providing for the review and disclosure of student educational records. The University and Outreach Programs-TRIO and GEAR UP will not permit access to or the release of personally identifiable information contained in student educational records to any party without the written consent of the student, except as authorized by FERPA 8 P a g e - g e 1 1. 1 7
RECOMMENDATION FORMS (To be completed by a Teacher, Counselor, or school staff member) Dear Teacher/Counselor: The student listed below is applying for admission into the TRiO Upward Bound Van Buren Program at Western Michigan University. Your assessment of the student s conduct, character and academic need for program services is an integral element in the admission process. Please give us your honest assessment of this student s desire and ability to learn. Please deliver the completed Recommendation Form to the front office at your high school s or your WMU Upward Bound Van Buren representative. Should you have any questions or concerns, please contact Gustavo Echavarria Upward Bound Van Buren Coordinator at 269-993-7871. The time and effort you have taken to complete this form is sincerely appreciated. Student s Name: Class/Course Subject: Current Class/Course Grade: Grade Level: School: Please place an "x" in the appropriate column for each characteristic listed below: STUDENT CHARACTERISTICS EXCELLENT AVERAGE FAIR POOR CONDUCT IN CLASS WILLINGLY PARTICIPATES IN CLASS RESPECTS OTHERS AND THEIR PROPERTY ABILITY TO FOLLOW INSTRUCTIONS COMPLETES ASSIGNED WORK ON TIME STUDY SKILLS/HABITS ANALYTICAL THINKING SKILLS MATURITY/INTEGRITY PUNCTUALITY EAGER TO LEARN NEW THINGS/INIATIVE DEMONSTRATES MOTIVATION TO COMPLETE A 6-WEEK SUMMER PROGRAM Please provide comments on motivation, behavior, personality, strengths or weaknesses that you feel are pertinent to the student s performance in Upward Bound. You may attach additional comments to this form. Teacher s/counselor s Printed Name & Title School Telephone Number Teacher s/counselor s Signature Date The Family Educational Rights and Privacy Act (FERPA), 20 U.S.C. 1232g., are respectively federal and state laws providing for the review and disclosure of student educational records. The University and Outreach Programs-TRIO and GEAR UP will not permit access to or the release of personally identifiable information contained in student educational records to any party without the written consent of the student, except as authorized by FERPA. 9 P a g e - g e 1 1. 1 7