West Virginia State University Pre-college Programs

West Virginia State University Pre-college Programs Upward Bound Math-Science and Classic Upward Bound are college preparatory programs designed to strengthen and enhance the critical thinking, scientific, and analytical skills of high school students. Through academic classes, group research, field trips, and recreation these programs help students increase skills, motivation and background necessary for successful entry into college. The Upward Bound/Upward Bound Math-Science programs work with students from the end of their 8 th grade year until they graduate from high school by preparing them to be the first in their families to attend college. Students are engaged in a rigorous course curriculum that is designed to prepare them to compete on a global stage. In addition, the Upward Bound Math-Science program emphasizes the STEM (Science, Technology, Engineering, and Math) disciplines by helping students recognize and develop their potential to excel in math and science. Academic-Year Component: Students receive year-round academic support through Saturday academic sessions, weekly after school tutorial sessions, and assistance with preparation for standardized exams. Participants have the opportunity to earn up to $400 in stipends throughout the academic year. Students will also receive a $60 stipend for attending the Summer Academy. Summer Academy: Participants attend a mandatory six-week Summer Academy on the campus of West Virginia State University and then enjoy an out-of-state educational and cultural enrichment trip. Program components include coursework in English, Math, Science, Computer Technology, and individualized research, in addition to educational activities. Activities and services are provided at no cost to students and all costs for the summer session including, books, supplies, room and board are free. Bridge Program: Participants who consistently meet project goals and attend summer sessions may become eligible to apply for the Bridge Program. Students eligible may take up to six credits of college coursework at WVSU in the summer immediately after graduating from high school. West Virginia State University UPWARD BOUND PROGRAMS PO Box 1000 Sullivan Hall 223 East Institute, West Virginia 25112 Phone: (304) 766-3120 or Fax: (304) 766-5122 Upward Bound Math-Science & Classic Upward Bound are federally funded TRIO programs

P.O. Box 1000, Sullivan Hall 223, Institute, WV 25112 Phone: 304.766.3120 Fax: 304.766.5122 Applicant Information & Assessment Student s Last Name: First Name: Middle: Social Security #: Date of Birth: Email Address: Current School: Current Grade Level: Student School ID #: 8 th 9 th 10 th 11 th 12th Mailing Address: Street and Apt. No. Citizenship: United States Citizen or Permanent Resident City: State: Zip: Home Phone Number: Student Engrade username: Cell Phone Number: Student Engrade password: Age: Ethnic Background: Gender: Male Female Have you had any legal interactions with the Department of Juvenile Services? Yes Hispanic White African American/Black American Indian Asian Other What are your favorite school subjects? What classes (if any) do you think you will need tutoring in? No What do you plan to do immediately after graduating from high school College Work Military Don t know Select the field that best describes the field or career you are interested in pursuing? Upward Bound Lawyer Teacher Banking Business Owner Psychologist Actor/Performer Social Worker Writer Counselor Communications Criminal Justice Graphic Design Fashion Designer Sociologist Education Athletic Trainer Veterinarian Historian Culinary Nurse Pharmacist Other Upward Bound Math-Science Engineer Pharmacy Architecture Accountant Chemist Actor/Performer Doctor Counselor Biologist Dentist Nurse Physicist Forensic Scientist Astronomer Computers Programmer X Ray Tech Veterinarian Physical Therapy Financial Advisor Researcher Other Please indicate the areas that you feel you would like to improve. Reading Public Speaking English proficiency Writing Interpersonal/Group Relations Achievement test scores Math Self-esteem and/or social skills Career goals Natural Sciences Study Skills Grade Point Other (specify)

Record & School Release Form Student s Last Name: First Name: Middle: Date of Birth: Social Security: RELEASE OF ACADEMIC RECORDS I authorize and give permission to the West Virginia State University Upward Bound Math-Science and Classic Upward Bound Staff to access and/or receive copies of my academic transcripts, grade reports, report cards, WESTEST scores, attendance reports, test results, Engrade, and any other information needed to monitor my academic progress. I also grant the Upward Bound Math-Science and/or Upward Bound Classic staff permission to speak with teachers, instructors, counselors and other school administrators at my child s school in order to obtain and exchange information as part of the services provided by the Upward Bound programs. I understand that the United States Department of Education requires the West Virginia State University Upward Bound Programs to report on my academic progress through either my graduation from college or for at least six years after my high school graduation. I understand the information released to the WVSU Upward Bound Programs will be used for my benefit up to six years after graduating from high school. I further understand the WVSU Upward Bound Programs are funded by the U.S. Department of Education and will use these records to provide academic advisement, follow-up and tracking. I also understand that the Privacy Act protects this information and that these records will be handled in a confidential manner and they will be made available only to program staff and representatives from Federal and State Departments of Education. I, as the parent or guardian of an Upward Bound Program participant, authorize the release of the information described above (including fax transmittal) on behalf of my minor child. A photocopy of this record release form should be accepted as an original and the date signed has no bearing to the date that the West Virginia State University Upward Bound Math-Science or the Upward Bound Classic Program or its staff requests the information. Student s Signature Date Parent s/guardian s Signature Date

School Counselor Assessment Form (To be completed by school counselor) I authorize the school officials to release information, school records or any documents to the WVSU Upward Bound programs and its staff to help determine program services that will benefit my child. Student s Last Name: First Name: Middle: Parent s Signature: Date: What is the student s current OVERALL GPA: PSAT: Verbal Written Math COUNSELOR S PLEASE ATTACH ALL TEST SCORES AND TRANSCRIPT BEGINNING WITH 7 TH GRADE Please check the student s WESTEST achievement for the following: Distinguished Class Level 7 th grade Math 7 th grade Reading 8 th grade Math 8 th grade Reading 9 th grade Math 9 th grade Reading 10 th grade Reading 10 th grade Math Above Mastery Mastery Partial Master Novice Did not take the assessment 1. Which of the following best describes this student's curriculum or pathway? Professional Skilled Entry 2. What is the student s cluster? Major? 3. How many days has this student missed school? 0-3 days 4-6 days 7-10 days 11 or more days 4. How many school disciplinary actions or suspensions does this student have? None 1-5 6 or more Students selected for the Upward Bound Programs must demonstrate a need for services we provide. How would you categorize this student s need? Please check all that apply. Low grade point average Lack of career goals and/or need for accurate information on careers Low achievement test scores Limited English proficiency Low educational aspirations Lack of confidence, self-esteem, and/or social skills Low GPA and low educational aspirations Predominately low income community Low GPA and low achievement test scores Rural isolation Low achievement test scores and low educational aspirations Interest in careers in math and science Lack of opportunity, support, and/or guidance to take Diagnosed learning disability challenging college preparation courses Other Please add additional comments on motivation, behavior, personality, strengths or weaknesses that you feel will help us in evaluating this student s application. Also indicate any academic, social support, special services, or IEP that this student is receiving. If this is the case, sometimes a short description of the situation may be helpful. If discretion is necessary, please supply the information in person or by the telephone. Counselor s Signature: Print Name: School: Date:

WVSU Upward Bound Math Science & Classic Upward Bound Student's Personal Statement & Essay Student s Last Name: First Name: Middle: 1. Please write an essay as to why you should be selected for one of the Upward Bound Programs at West Virginia State University. In this essay please tell us about your goal, aspirations and how Upward Bound Math-Science or Classic Upward Bound can help you achieve these goals. Please organize your thoughts and use correct spelling, grammar, and punctuation.

Family & Income Information (To Be Completed by Parent/Guardian) - - THIS SECTION MAY BE MAILED IN SEPARATELY BY PARENT OR GUARDIAN Student s Last Name: First Name: Middle Name: Who does the student currently live with? Mother Father Both Parents Guardian Is the applicant a foster child or a ward of the court? No Yes Caseworker s Name and Phone number: MOTHER/FEMALE GUARDIAN Name: Home/cell phone number: Address: City: State: Zip: Employer: Occupation: Please check the highest level of education you have completed: High school Some college Four-year college degree FATHER/MALE GUARDIAN Name: Home/cell phone number: Address: City: State: Zip: Employer Occupation Please check the highest level of education you have completed: High school Some college Four-year college degree Name (Last, First) List everyone in the Household. Attach a separate sheet if needed. Relationship to Applicant Age School/Occupation 1. 2. 3. 4. 5. 6. The financial information requested below is required by the U.S. Department of Education to determine your son/daughter s eligibility for Upward Bound. You must include all taxable potential household income. The Taxable income is located on the second page of your 1040 tax return. Yearly Taxable Income: $ Child Support: $ TANF: $ Social Security: $ V. A. Benefits: $ Retirement: $ Unemployment: $ Other: $ The Upward Bound Programs are funded by the U.S. Department of Education and are intended to serve first-generation or low-income students who want to go to college. We base eligibility on 'taxable' income. You must submit a copy of your signed income tax form for last year OR If you did not file income tax, please submit document(s) to verify total income from AFDC, Social Security, Unemployment, Disability, Veterans Benefits, or other income. All information provided is confidential I certify that the above information is true to the best of my knowledge. Parent s/guardian s Signature: Date:

Consent, Liability Release Form Student s Last Name: First Name: Middle Name: In consideration for being accepted by West Virginia State University for participation in an Upward Bound Programs. I (we), on behalf of my child do hereby release, forever discharge and agree to hold harmless West Virginia State University and the West Virginia State University Upward Bound Programs and the staff thereof from any and all liability, claims or demands for personal injury, sickness, or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the child that may occur while said child is participating in the above described program. Furthermore, I (we) and on behalf of my (our) child hereby assume all risk of personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein. Further, authorization and permission is hereby given to said program to furnish any necessary transportation, food and lodging for this participant. The undersigned further hereby agree to hold harmless and indemnify said university, its administrators, and employees, for any liability sustained by said initiative as the result of the negligent, willful or intentional acts of said participant, including expenses incurred. I (we), the parent(s) or legal guardian(s) of this participant, and hereby grant my (our) permission for him/her to participate fully in said program, and hereby give my (our) permission to take said participant to a doctor or hospital and hereby authorize medical treatment, including but not in limitation to emergency surgery or medical treatment, and assume the responsibility of all medical bills, if any. Further, should it be necessary for the participant to return home due to medical reasons, disciplinary action or otherwise, I (we), hereby assume all transportation costs. Parent s/guardian s Signature: Date: Parent s/guardian s Signature: Date: Publicity Release Form Upward Bound Math-Science, Classic Upward Bound or West Virginia State University staff may include my name, statements or photo in publications including brochures, recruiting materials, web sites, press releases, Upward Bound social media site, and other publications which feature the Upward Bound programs or highlight participant s achievements and accomplishments. Student s Signature: Date: Parent s/guardian s Signature: Date:

Medical Authorization and Consent Form Throughout the year, students participate in a variety of field trips; therefore, it is necessary that accurate medical history is provided in the event that emergency treatment is required. All information is confidential. Any student without a completed and signed Medical Authorization form will not be allowed to participate in any Upward Bound activity. Student s Last Name: First Name: Middle: Social Security #: Date of Birth: Mailing Address: Street and Apt. No. City: State: Zip: Home Phone Number: Parent Cell Phone Number: Emergency Contact Name and Phone # if unable to contact parent: Grandparent or closest relative name and phone: Is your child currently insured? Yes No Policy Holder s Name: Insurance Company Name: Physician s Name: Medical Insurance Information Attach a copy of the front and back of student s insurance card Medical History of Student Check all items and provide detail if answer is checked Policy#: Group #: Physician Phone #: Diabetes Allergies to medication Allergy to food or plants Low Blood Sugar Insect Bite Allergy Nervous Disorder Hearing Defects Convulsions/Epilepsy Heart Disease Asthma Currently taking medication ADHD / ADD Special diet or food restriction Physical restrictions Eczema/ Skin Disorders Currently under doctor s care Stomach/Indigestion Other Date of last physical: Date of last tetanus shot: List any physical limitation/illnesses List all known allergies If currently taking medication indicate type and reason: List details to items marked [yes]: I understand that should a health emergency arise, I will be notified as soon as possible and medical treatment as deemed necessary by medical personnel is authorized. Other than medical emergency, I authorize WVSU staff to examine and treat my child in the same way that West Virginia State University students are treated with notification of parents being dependent on the judgment of the physician. In addition, I agree to indemnify and save and hold harmless West Virginia State University, its officers, agents and employees from and against any and all claims and liabilities which may arise out of or result from or be in any way connected directly or indirectly while participating in the program. Student s Signature: Parent s/guardian s Signature: Date: Date:

Mathematics Teacher Assessment Dear Teacher: We appreciate your cooperation and candor in completing this form. This student is applying for admission into an Upward Bound Program at West Virginia State University. Your assessment of this student is a crucial element in the selection process. Please fax the completed recommendation form to (304) 766-5122. You may also return the completed recommendation form to the student or counselor in a sealed envelope to submit with his/her completed student application. Should you have any questions or concerns, please feel free to contact us at (304) 766-3120. Student s Name: School: Class/Course Subject name: Please assess this student s grade level in the following areas: Classroom Below At Above Math Skills Study Skills Below At Above Knowledge of the basic skills Accuracy in use of basic skills Below At Above Memorization Demonstrates an active interest in learning Organization Problem solving ability Participates in discussions Note-taking Reasoning ability Brings academic tools to class Expression of Concepts Command of Concepts Expression of Concepts Understanding of underlying ideas and concepts Retention of subject matter Characteristic Interest in learning Leadership displayed Intellectual Curiosity Self-motivation/initiative Creativity Prepared or class daily Commitment to homework Participation in class Quality of class notes Ability to express ideas orally Ability to express ideas in writing Ability to work independently Ability to work in small groups Onetime class attendance Assignment completion Homework complete Outstanding Above Below No Basis for judgment Comments Teacher s Name: Date: Email: Student s grade in this course is:

English Teacher Assessment Dear Teacher: We appreciate your cooperation and candor in completing this form. This student is applying for admission into an Upward Bound Program at West Virginia State University. Your assessment of this student is an integral element in the selection process. Please fax the completed Recommendation Form to (304) 766-5122. You may also return the completed Recommendation Form to the student or counselor in a sealed envelope to submit with his/her completed student application. Should you have any questions or concerns, please feel free to contact us at (304) 766-3120. Student s Name: School: Class/Course Subject name: Please assess this student s grade level in the following areas: Math Skills Study Skills Below At Above Classroom Below At Above Knowledge of the basic skills Below At Above Memorization Accuracy in use of basic skills Demonstrates an active interest in learning Organization Problem solving ability Participates in discussions Note-taking Reasoning ability Brings academic tools to class Expression of Concepts Command of Concepts Expression of Concepts Understanding of underlying ideas and concepts Retention Characteristic Interest in learning Leadership displayed Intellectual Curiosity Self-motivation/initiative Creativity Prepared or class daily Commitment to homework Participation in class Quality of class notes Ability to express ideas orally Ability to express ideas in writing Ability to work independently Ability to work in small groups Onetime class attendance Assignment completion Homework complete Outstanding Above Below No Basis for judgment Comments Teacher s Name: Date: Email: Student s grade in this course is: