Chicago State University Upward Bound Programs On-line Application

Chicago State University Upward Bound Programs On-line Application Dear Applicant: On behalf of the students and staff of the Upward Bound Programs and Chicago State University, we want to thank you for your interest in our program. We are very proud of our programs and invite you to apply. By completing this application, you are taking a vital step that will put YOU in control of your future. Each year there are approximately thirty openings, therefore, it is very important that you do your very best when you complete this application. Read the instructions below to assist you. If you have any questions, please feel free to call the Upward Bound Programs office at 773.995.2566. Best regards, The Upward Bound Programs Staff STUDENT ADMISSION GUIDE (Please Read then Proceed) 1. FIRST, please read Upward Bound Programs Website Information. Make certain you and your parent(s)/guardian understand what the program is and that you really want to become a part of Upward Bound Programs. 2. THEN, please READ (PAGES 1 7) the ENTIRE application BEFORE answering any questions. 3. Please use BLACK INK and PRINT all information (except signatures, of course). 4. Answer each question THOROUGHLY and CAREFULLY. DO YOUR BEST! 5. Make certain your parent/guardian signs the School Records Release on page 3 and that they complete and sign the Family Financial Statement on pages 7. 6. The application contains three (3) Evaluation Forms: one each for your Counselor, Mathematics or Science Teacher, and English Teacher. There is also a General Recommendation Form which may be completed by an adult (not a relative) who knows you well. Be sure to give all four forms to the correct people and ask them to return the forms directly to the Upward Bound office at Chicago State University. 7. Please answer all four (4) essay questions on page 4. Do NOT get help with the essay questions. We want to know what YOU have to say. (PLEASE PRINT) 8. Please complete the Student Self-Assessment of Skills and Survey of Interest on pages 5 and 6. 9. As soon as you and your parent/guardian have completed the application, please send or bring it to the Upward Bound office. Do NOT wait for the Evaluations and Recommendation forms. The evaluation and recommendation forms will be mailed directly to our office. 10. When all your forms, including the Evaluation and Recommendation forms, have been received by the Upward Bound office we will contact you to arrange for an interview.

(Please type or print your application in black ink.) On-Line Upward Bound Programs STUDENT APPLICATION PAGE 1 of 7 PERSONAL DATA SOCIAL SECURITY NO.: NAME: (LAST) (FIRST) (MIDDLE) ADDRESS: CITY: STATE: ZIP CODE: TELEPHONE NO.: ( ) Email Address BIRTH DATE: SEX: MALE FEMALE What is your ETHNIC GROUP? (Your response to this question will not affect the admission decision and is OPTIONAL.) Asian or Pacific Islander Black, Non-Hispanic Hispanic American Indian/Alaskan Native White, Non-Hispanic Other: U.S. CITIZEN? YES NO Which country are you a citizen? Please list any language(s) OTHER THAN ENGLISH spoken at home: ************************************************************************************************************************************ WHAT GRADE ARE YOU IN NOW? WHAT GRADE WILL YOU BE IN NEXT YEAR? WHAT SCHOOL DO YOU ATTEND? ELEMENTARY HIGH SCHOOL If you are in Elementary School, please complete this section: HOMEROOM TEACHER: COUNSELOR: What High School will you attend next year? If you are in High School, please complete this section: DIVISION TEACHER: COUNSELOR: DIVISION NUMBER: When did you receive your most recent progress report card? Month: Year: Copy Attached? YES NO Please list your courses and the grades you received on your most recent report card: COURSE GRADE COURSE GRADE 1. 5. 2. 6. 3. 7. 4. 8.

UB STUDENT APPLICATION * page 2 of 7 How did you find out about Chicago State University s UPWARD BOUND PRORAMS? School Counselor Upward Bound Student School Announcement School Teacher Upward Bound Staff Family or Friends School Principal Upward Bound Brochure/Poster Other (please indicate) ************************************************************************************************************************************ (PRINT YOUR FULL LEGAL NAME HERE) SCHOOL RECORDS RELEASE FORM I, hereby consent to the release of my school records. This includes my high school transcripts, report cards, test scores, college placement records and other information regarding my school performance to Chicago State University s Upward Bound Programs from the date this School Records Release Form is signed until I am placed in a college. (PRINT PARENT/LEGAL GUARDIAN NAME HERE) I,, as the parent or legal guardian of the above named student, do hereby consent to the release of the school records as noted above. STUDENT SSN#: STUDENT School ID#: DATE OF BIRTH: ADDRESS: STUDENT SIGNATURE: DATE: PARENT/GUARDIAN SIGNATURE: DATE:

UB STUDENT APPLICATION * Page 3 of 7 ESSAY QUESTIONS The purpose of these essay questions is to help the Upward Bound Programs understand you and what you hope to accomplish in the future. Please answer the four questions below as thoroughly as possible. Feel free to attach an additional page if there is other information which you feel would be helpful to Upward Bound Programs in considering your application for admission. 1. In what ways do you expect to benefit from your participation in Upward Bound? 2. What type of effort will you put forth to meet your expectation? 3. Please describe your plans following your high school graduation? 4. What kind of career do you think you might like to have? Please give your reasons. 5. What person or event has had a significant influence upon your life? Please describe how that person or event has affected you.

UB STUDENT APPLICATION * Page 4 of 7 STUDENT NAME: STUDENT SELF-ASSESSMENT OF SKILLS AND SURVEY OF INTERESTS You are to be congratulated for having completed the major portion of this application. Obviously you are serious about yourself and preparing for your future. Following the completion of this form, both you and your parent/guardian will be scheduled for an interview with the Upward Bound staff. To assist the staff in this stage, please complete the sections below. Be very honest about your skills and capabilities. Upward Bound Programs provides the opportunity for you to get the assistance you need. The information you provide can not hurt your chances for admission. The staff simply needs to know the areas and the extent of your experiences and your needs. In other words, we need to know how best to help you. You are the one who can best help us assist you in your development. SKILLS AREA Please use the following codes to complete this section: 5 - I am very strong in this area, strong enough to tutor fellow students 4 - I need very little or no help in this area 3 - I need to improve in this area, because my skills are average 2 - I need some help in this area 1 - I need a lot of help in this area 0 - I need intensive help in this area YOUR RESPONSE 1. GRAMMAR... 0 1 2 3 4 5 2. SPELLING... 0 1 2 3 4 5 3. WRITING MECHANICS... 0 1 2 3 4 5 4. COMPOSITIONS AND ESSAYS... 0 1 2 3 4 5 5. RESEARCH PAPERS... 0 1 2 3 4 5 6. LIBRARY USAGE AND RESEARCH METHODS... 0 1 2 3 4 5 7. GENERAL READING AND COMPREHENSION... 0 1 2 3 4 5 8. CRITICAL READING AND ANALYSIS... 0 1 2 3 4 5 9. STUDY SKILLS... 0 1 2 3 4 5 10. LECTURE NOTETAKING... 0 1 2 3 4 5 11. LISTENING SKILLS... 0 1 2 3 4 5 12. TEXTBOOK MARKING AND NOTETAKING... 0 1 2 3 4 5 13. EXAMINATION PREPARATION... 0 1 2 3 4 5 14. TEST-TAKING SKILLS... 0 1 2 3 4 5 15. ARITHMETIC... 0 1 2 3 4 5 16. PRE-ALGEBRA... 0 1 2 3 4 5 17. ELEMENTARY ALGEBRA... 0 1 2 3 4 5 18. INTERMEDIATE ALGEBRA... 0 1 2 3 4 5 19. PLANE GEOMETRY... 0 1 2 3 4 5 20. ADVANCED ALGEBRA-TRIGONOMETRY... 0 1 2 3 4 5 21. PRE-CALCULUS... 0 1 2 3 4 5 22. SCIENTIFIC INQUIRY METHOD... 0 1 2 3 4 5 23. BIOLOGY... 0 1 2 3 4 5 24. PHYSICS... 0 1 2 3 4 5 25. CHEMISTRY... 0 1 2 3 4 5 26. FOREIGN LANGUAGE (SPOKEN):... 0 1 2 3 4 5 27. FOREIGN LANGUAGE (WRITTEN):... 0 1 2 3 4 5 28. COMPUTER SCIENCE LITERACY... 0 1 2 3 4 5 29. COMPUTER SCIENCE LANGUAGE:... 0 1 2 3 4 5 30. SPEAKING ABILITY... 0 1 2 3 4 5

UB STUDENT APPLICATION * Page 5 of 7 What is your interest in the following activities? Please place a number beside each selection according to the following codes: 0 - No interest 1 - Very little interest 2 - Some interest 3 - Very interested ELECTIVE COURSES AND SEMINARS CLUBS MODERN DANCE NEWSLETTER DESKTOP PUBLISHING POETRY WRITING /APPRECIATION LITERATURE MEDIA WATCH AFRICAN DANCE ENTREPRENEURS OF THE FUTURE ARTS AND CRAFTS YEARBOOK SCULPTURE PHOTOGRAPHY LEADERSHIP DEVELOPMENT BIBLE STUDY JOURNALISM MARTIAL ARTS DRAMA JOGGING ORAL INTERPRETATION/SPEECH GOSPEL CHOIR POETRY READING AEROBIC EXERCISE SWIMMING TENNIS PERSONAL GOAL DEVELOPMENT SOCCER THIRD WORLD STUDIES PING PONG AFRICAN STUDIES BOWLING STUDY OF CHICAGO HANDBALL RELIGION STUDENT GOVERNMENT ASSOC. MALE-FEMALE RELATIONSHIPS OTHER ATHLETIC TEAMS SOFTBALL VOLLEYBALL BASKETBALL TRACK AND FIELD TENNIS List all the activities, clubs and teams you participate in either in school or in your community:

UB STUDENT APPLICATION * Page 6 of 7 FAMILY ELIGIBILITY STATEMENT To be completed by the parent(s) or legal guardian of the student applicant Upward Bound designed for students who are potential first-generation college students and/or from low-income families. The information provided on this form is necessary to make certain that the student is eligible for the program. Of course, this information will be held in strictest confidence. If you have any questions, please call the Upward Bound office. PARENT(S)/GUARDIAN PERSONAL DATA Circle one: Mother Legal Guardian Foster Parent Circle one: Father Legal Guardian Foster Parent NAME: ADDRESS: CITY: STATE/ZIP CODE E-mail Address: NAME: ADDRESS: CITY: STATE/ZIP CODE E-mail Address: DOB: SS#: DOB: SS#: U.S CITIZEN? YES NO U.S CITIZEN? YES NO EMPLOYER: ADDRESS: CITY: ZIP CODE: EMPLOYER: ADDRESS: CITY: ZIP CODE: TELEPHONE NO: ( ) TELEPHONE NO: ( ) YOUR POSITION: YOUR POSITION: * * * * * * * * * * * * * * * * * * * DID YOU ATTEND COLLEGE? YES NO DID YOU ATTEND COLLEGE? YES NO If YES, complete this section below: NAME OF COLLEGE: If YES, please complete this section below: NAME OF COLLEGE: Bachelor s Degree Completed? YES NO Bachelor s Degree Completed? YES NO YEARS ATTENDED: YEARS ATTENDED: PARENT/GUARDIAN DECLARATION I/We declare that the college information provided above is true and correct. Signature of Mother/Female Guardian Date Signature of Father/Male Guardian Date

UB STUDENT APPLICATION * Page 7 of 7 The U.S. Department of Education requires that we document the family income for each student who is admitted to the program. You must submit a copy of your MOST RECENT tax return (Form 1040 or 1040-A) with this form. If you did not file a tax return or one is not available, then please submit a copy of other documentation of income, such as: 1. Your most recent Public Aid Medical Card and Illinois LINK card (front and back). 2. Check stubs from your most recent Social Security check, SSI check, pension check, etc. Please list yourself and all other persons who live in your household and their monthly income. Write 0" if the person has no monthly income. In addition, list all your dependents. HOUSEHOLD MEMBER Gross Monthly Earnings (Before Deductions) JOB 1 JOB 2 Monthly Welfare Payments, Child Support, Alimony Any Other Monthly Income Retirement, Social Security, SSI, Unemployment 1. $ $ $ $ 2. $ $ $ $ DEPENDENTS AGE RELATIONSHIP GRADE IN SCHOOL LIVING AT HOME ( Yes/No) If your family receives Public Assistance, please provide a copy of your most recent State of Illinois Medical Card. If you are the foster parent, please provide a copy of your most recent State of Illinois Medical Card. As applicable, please provide the following: CASE WORKER NAME:: CASE NO: SIGNATURE AND SOCIAL SECURITY NUMBER My signature certifies that all of the above information is true and correct and that all income is reported. I understand that this information is being given to determine the student applicant s eligibility for Upward Bound; that Upward Bound staff may verify the information on the application; and that deliberate misrepresentation of the information may cause the applicant to be denied admission to the Upward Bound Programs at Chicago State University. Signature of Mother/Female Guardian/Foster Parent Date Social Security Number Signature of Father/Male Guardian/Foster Parent Date Social Security Number PLEASE DO NOT WRITE IN THIS BOX: FOR OFFICE USE ONLY! DATE: DIRECTOR SIGNATURE: ACCEPTED: 1st Generation REJECTED: Not 1st Generation Low-income Not Low-income Academic Need Other: COMMENTS:

COUNSELOR S EVALUATION TO THE APPLICANT: Complete ONLY the top portion of this from and give it to your counselor to complete. PLEASE PRINT ALL INFORMATION. (NOTE: If you are in 8th grade and do not have a counselor, then please give this form to your Home Room Teacher or Division Teacher-whichever person has your transcript and academic records.) NAME: SOCIAL SECURITY NO: ADDRESS: CITY: STATE: ZIP CODE: SCHOOL: CURRENT GRADE: APPLICANT: DO NOT WRITE BELOW THIS LINE ---------------------------------------------------------------------------------------------------------------- To the Counselor: In addition, to completing the questionnaire below, PLEASE FORWARD AN OFFICIAL COPY OF THE STUDENTS CURRENT TRANSCRIPT (BEGINNING WITH GRADE 6, IF POSSIBLE) INCLUDING ALL AVAILABLE TEST SCORES. (NOTE: A School Records Release Form signed by both the student and his parent/guardian is on file in the Upward Bound Programs office and upon your request, a copy of this form can be sent to you, if necessary.) Please feel free to attach any additional information you feel may be helpful. Please return this evaluation and all other items and information directly to: Chicago State University Upward Bound DH Ste. K 9501 S. King Drive Chicago, Illinois 60628-1598 773-995-2566 www.csu.edu/trio NAME: TELEPHONE NO: ( ) YOUR TITLE: DIVISION TEACHER COUNSELOR HOMEROOM TEACHER HOW LONG HAVE YOU KNOWN THE APPLICANT? IN WHAT TYPE OF CURRICULUM IS HE/SHE ENROLLED? STUDENT S CURRENT GPA: CLASS RANK: Please list the courses the student is now taking and his/her most recent grades. Has the student made normal progress in school? YES NO Please describe:

Does the student have any physical disabilities? If yes, please describe the nature of the disability and the affect it has on the student. Does the student have any emotional disabilities or behavioral problems that may require clinical help? If yes, please describe. Describe the students overall academic performance. What do you feel are the student s personal strengths and weaknesses? Please be specific. What would you consider to be this student s level of maturity? In your opinion is s/he a self-starter? Does s/he accept responsibility? Is s/he generally a leader or a follower? In the space provided below, please give a brief summary of the ways in which you feel Upward Bound might be of benefit to this student. SIGNATURE: DATE:

ENGLISH TEACHER S EVALUATION Chicago State University Upward Bound DH Ste. K 9501 S. King Drive Chicago, Illinois 60628-1598 773-995-2566 www.csu.edu/trio TO THE APPLICANT: Complete ONLY the top portion of this from and give it to your English Teacher to complete. PLEASE PRINT ALL INFORMATION. NAME: SOCIAL SECURITY NO: ADDRESS: CITY: STATE: ZIP CODE: SCHOOL: CURRENT GRADE: APPLICANT: DO NOT WRITE BELOW THIS LINE ---------------------------------------------------------------------------------------------------------------- TEACHER S NAME: COURSE TITLE: DAY PHONE NUMBER: ( ) TIME AVAILABLE: HOW LONG HAVE YOU KNOWN THE APPLICANT? Please circle the appropriate number regarding the LOW HIGH student named above: Ability to use fundamentals of grammar, mechanics 1 2 3 4 5 Ability to organize ideas 1 2 3 4 5 Can express ideas clearly and logically 1 2 3 4 5 Ability to form original ideas 1 2 3 4 5 Ability to write coherently 1 2 3 4 5 General reading skills 1 2 3 4 5 Retention of ideas and data presented in assignments 1 2 3 4 5 Ability to make inferences 1 2 3 4 5 Ability to make comparisons/contrasts 1 2 3 4 5 Ability to make critical evaluations 1 2 3 4 5 Ability to make valid judgments 1 2 3 4 5 Vocabulary 1 2 3 4 5

What are the student s habits in regard to attendance and punctuality? Describe the student s attitude towards your course. Does academic work seem to have meaning and significance to him/her? What evidence can you provide which suggests that the student is motivated? Describe the student s overall class performance using examples wherever possible. In your opinion, does the student use his/her study time well? Does he/she take excessive time to complete reading or writing assignments? In your judgment, is the student working up to his/her intellectual/academic potential? If not, why do you think he/she is not? Is the student capable of handling advanced work? What would you consider to be the student s level of maturity? In your opinion is he/she a self-starter? Does he/she accept responsibility? Is she/he generally a leader or a follower? Describe the student s degree of participation in class discussions and group work. In your opinion, does the student contribute meaningfully to class discussions? In the space provided below, please give a brief summary of the ways in which you feel Upward Bound Programs might be of benefit to this student: TEACHER SIGNATURE: DATE:

GENERAL RECOMMENDATION/EVALUATION FORM Chicago State University Upward Bound DH Ste. K 9501 S. King Drive Chicago, Illinois 60628-1598 773-995-2566 www.csu.edu/trio TO THE APPLICANT: Complete ONLY the top portion of this from and give it to any person who knows you well. (Minister, employer, etc.) PLEASE PRINT ALL INFORMATION. NAME: SOCIAL SECURITY NO: ADDRESS: CITY: STATE: ZIP CODE: SCHOOL: CURRENT GRADE: APPLICANT: DO NOT WRITE BELOW THIS LINE ---------------------------------------------------------------------------------------------------------------- Individual completing this evaluation What is your relationship to the student? What is your title? Agency Address: City: State: Zip: Telephone No: ( ) How long have you known the applicant? GOAL ORIENTATION: Is the student goal oriented or does he/she tend to take things as they come? In your opinion, what are the student s educational and career goals? What evidence can you provide which suggests that the applicant is working to reach his/her goals? MOTIVATION: In what areas is the applicant motivated to perform well (such as sports, hobbies, academic, interpersonal relationships, etc.)? Please give evidence of the evidence of the student s interests. WILLINGNESS TO WORK: Does the applicant apply him/her self to a task? Is he/she thorough? Does he/she work independently or does he/she usually need fairly close supervision?

INTERPERSONAL RELATIONSHIPS: How does the student relate to peers, family, authority figures, etc? Does he/she work well with others in group settings? MATURITY: How would you describe the applicant s maturity level? Is he/she a self-starter? Does he/she accept responsibility? Is he/she generally a leader or a follower? POTENTIAL: What would you realistically regard as this student s potential (in any areas which you are familiar with, such as academics, athletics, art, choir, etc.)? PERSONAL HABITS: Please comment upon the student s character and personal strengths and weaknesses (such as dependability, attitude, seriousness of purpose, dedication, etc.). Please state how you feel the applicant will benefit from his/her participation in Project FAME/Upward Bound. Also, in what ways do you feel the student will contribute to the program? Please feel free to use this space to add any comments which you feel might assist Upward Bound Programsin evaluating this applicant? SIGNATURE: DATE:

MATH/SCIENCE TEACHER S EVALUATION Chicago State University Upward Bound DH Ste. K 9501 S. King Drive Chicago, Illinois 60628-1598 773-995-2566 www.csu.edu/trio TO THE APPLICANT: Complete ONLY the top portion of this from and give it to your Math/Science Teacher to complete. PLEASE PRINT ALL INFORMATION. NAME: SOCIAL SECURITY NO: ADDRESS: CITY: STATE: ZIP CODE: SCHOOL: CURRENT GRADE: APPLICANT: DO NOT WRITE BELOW THIS LINE ---------------------------------------------------------------------------------------------------------------- TEACHER S NAME: COURSE TITLE: DAY PHONE NUMBER: ( ) TIME AVAILABLE: HOW LONG HAVE YOU KNOWN THE APPLICANT? years. Please circle the appropriate number regarding the student named above: LOW HIGH Understand basic arithmetic concepts (addition, subtraction, multiplication, division, percentages and fractions) 1 2 3 4 5 Ability to apply basic defined algebraic terms 1 2 3 4 5 Order of operations 1 2 3 4 5 Can group symbols and expressions containing powers 1 2 3 4 5 Can evaluate phrases or sentences 1 2 3 4 5 Can use distributive property and combine like terms 1 2 3 4 5 Understands equations involving a basic operation 1 2 3 4 5 Understands equations involving several operations or like terms 1 2 3 4 5 Understands signed numbers 1 2 3 4 5 Ability to make critical evaluations 1 2 3 4 5 Understands equations which have variables in both 1 2 3 4 5 Can solve two equations with two variables 1 2 3 4 5

What are the student s habits in regard to attendance and punctuality? Describe the student s attitude towards your course. Does academic work seem to have meaning and significance to him/her? What evidence can you provide which suggest that the students is motivated? Describe the students overall class performance using examples wherever possible? In your opinion, does the student use his/her study time well? Does he/she take excessive time to complete reading or writing assignments? In your judgment, is the student working up to his/her intellectual/academic potential? If not, why do you think he/she is not? Is the student capable of handling advanced work? What would you consider to be the student s level of maturity? In your opinion is he/she a self-starter? Does he/she accept responsibility? Is he/she generally a leader or a follower? Describe the student s degree of participation in class discussions and group work. In your opinion, does the student contribute meaningfully to class discussions? In the space provided below, please give a brief summary of the ways in which you feel Upward Bound Programs might be of benefit to this student: TEACHER SIGNATURE: DATE: