Student Application GENERAL INFORMATION Name Address Street City Zip code Phone Number ( ) Message/Cell Phone ( ) Birth date Social Security Number Check Which Applies: Female Male African-American Latino Native American Anglo Asian Other Are you a U.S. Citizen? Yes No (Alien Registration Card number) Grade in School: rising 9 9 10 11 Name of high school the applicant is currently attending ID# Are you covered by your parent's insurance? (If yes, please list company and any numbers necessary for identification, including Medicaid): Accepted: Yes No Director's Signature For Office Use Only # 20, Academic Need Enter 1st code here 2 nd code here Low-Income 1 st. Generation P.O. Box 173362 Campus Box 66 Denver, CO. 80217-3362 (303) 556-2812 Fax (303) 556-2516 Revised September, 2014
WHAT IS TRiO UPWARD BOUND? TRIO Upward Bound The federal TRIO Upward Bound Program is designed to increase the rate at which participants complete their high school education, enroll in and graduate from institutions of postsecondary education. Upward Bound provides fundamental support to participants in their preparation for college entrance. The successful student accomplishes the following goals: 1) Develops the necessary skills and motivation to graduate from high school and to complete post- secondary education. 2) Gains a sense of career possibilities and opportunities based on seminars, research projects, field trips, and on-the-job training. WHO CAN PARTICIPATE? An individual is eligible for TRiO Upward Bound if he/she: 1) Is ending the 8th grade, or has not yet completed the 1 st semester of the 11th grade. 2) Attends a designated target school. 3) Comes from a family whose taxable income does not exceed the income level set forth by federal government regulations. 4) Has academic potential and a desire to attend college. HOW TRiO UPWARD BOUND WORKS TRiO Upward Bound consists of an academic year program and a summer program both components are required. During the academic year the program provides: 1) Classes in English/Communications, Math, and Tutorial Sessions. 2) Specially-trained tutors and instructors who help strengthen academic skills in subjects required for high school graduation. 3) Personnel who coordinate motivational activities through individual and group sessions. The summer program is an intensive six week continuation in Career Exploration, Computer Science, Engineering, Foreign Language, Literature, Mathematics, and Science. Each individual will have classes designed to satisfy the student's educational needs and goals. Throughout the summer, the student and instructor will work together on specific skills. Tutors will also be used to aid this process. If a student is willing to put forth the commitment, he or she will gain concrete career and educational skills. 2
Student's Name: PARENT FINANCIAL REPORT - PLEASE ATTACH A COPY OF YOUR CURRENT 1040 TAX FORMS WITH W/2 s, AND ALL SCHEDULES THIS FORM IS TO BE FILLED OUT BY THE PARENT OR GUARDIAN TRiO Upward Bound is a program designed for students from low-income and first generation families. The following information is required by the federal government and should be accurate and complete. Your responses will be held in the strictest confidence. You must submit a signed copy of your Income Tax forms. With whom does the student live? (Check box and fill in names.) Mother and Father Mother and Stepfather Father and Stepmother Mother Father Other Additional Income (per month): Total Family Income: $ yearly before taxes. Number of dependents claimed on Income Tax Report:. 1. Part-time employment 2. Pension 3. Military pension 4. Social Security 5. TANF 6. Child support Please list all children or dependents that live with you in your home: Highest Grade Name Age Relationship Occupation Completed Do you live in a federal public housing project? Yes No Residence: Urban Rural Own Rent Type of dwelling: Multifamily Public Housing Foster Home Single Family Institutional What was the last year of school completed by: Father Mother Does the parent with whom you live have a four year college degree? Yes (type) No Signature(s) (Parents/Guardians) DATE 3
Disclosures PRIVACY ACT The personal information you give to the TRiO Upward Bound Director is protected by the Family Educational Rights and Privacy Act (FERPA). No one may view the information unless they work with or for the TRiO Upward Bound Program or are specifically authorized to do so. This information is necessary to determine whether the applicant is eligible to participate in the program. The Department of Education has the authority to gather information to strengthen services (20 USC 123a). If you do not give the TRiO Upward Bound Program this information the applicant cannot receive any benefits from the program. VERIFICATION OF INFORMATION By signing below, you are verifying that the information you provide on this application is true and correct to the best of your knowledge: Parent/Guardian signature TRiO UPWARD BOUND MEDICAL RELEASE Medical Concerns (e.g., diabetes, etc.): In the event that I, cannot be contacted (Parent/Guardian) during a medical emergency involving my son or daughter, I hereby authorize the staff of TRiO Upward Bound at Metropolitan State University of Denver to take the appropriate action(s) in securing professional medical attention. I further grant permission for the staff of the TRiO Upward Bound Program to dispense over-the-counter medications as needed or requested (i.e., Acetaminophen, Ibuprofen, allergy and/or cold medicines, etc.). Parent/Guardian signature Because the TRiO Upward Bound Program is liable for the well-being of all program participants, the following questions must be answered. Refusal to do so could eliminate your son/daughter from consideration for program participation. Has your son/daughter ever been suspended from school? Y N Is your son/daughter currently involved in any personal legal proceedings or dealing with the juvenile probation department? Y N Is your son/daughter required to participate in any behavior/anger modification Programs? Y N By signing below, you are verifying that the information you have provided on this application is true and correct to the best of your knowledge: Parent/Guardian signature 4
Student Contact Form PERSONAL INFORMATION Name: Age: Sex: Birthdate: Phone: ( ) Race: HIGH SCHOOL INFORMATION High school counselor s name: Present year in school: Expected graduation date: Subjects in which you perform well: Why? Subjects in which you have difficulty: Why? Do you participate, or plan to participate in high school sports? Y N If yes, which sports? Other extra-curricular activities: i.e., drama/dance club, student council, cheerleading, etc. Are you presently employed? Y N If yes, where? What type of college/university would you like to attend? two-year four-year In-state Out-of-state 5
PARENT/GUARDIAN INFORMATION Complete the following information for the parent(s)/guardian(s) with whom the applicant lives: Name(s): Address: Phone: ( ) Relationship to applicant: Occupation: Work number: ( ) If the applicant is a ward of the court or in a foster home, please complete the following: Name of resident agent: Case Worker: Please give a brief history of this placement: has my permission to be a participant in the TRiO Upward Bound Program. We understand and agree to his or her participation in all activities, inclusive of photo opportunities; academic and leadership sessions; volunteer/community commitments; and cultural, social and recreational engagements, both on and off the Auraria/Metropolitan State University of Denver campus. Parent/Guardian Signature 6
(Writing sample) To be considered for the TRiO Upward Bound Program, please answer the following questions: (Please feel free to attach a separate sheet of paper if you need more space) Why is education important to you? If selected as a participant, what specific strength can you contribute to TRiO Upward Bound? LIST ALL PRE-COLLEGIATE AND/OR COLLEGE ACCESS PROGRAMS YOU CURRENTLY PARTICIPATE IN. (i.e. TRiO Talent Search, Gear-Up, AVID, Colorado Uplift, etc.) I understand the purpose of the program offered by TRiO Upward Bound. If accepted, I agree to participate fully in the academic year and summer component of the program. I also agree to comply with any rules and regulations established by the Director and staff of TRiO Upward Bound with the understanding that failure to comply could result in termination from the Program. Student Signature For more information contact the TRiO Upward Bound office @ Metropolitan State University of Denver, Campus Box 66, P.O. Box 173362, Denver, CO 80217-3362, or call (303) 556-2812. 7
STUDENT and PARENT/GUARDIAN CONTRACT Students who are accepted into the TRIO UPWARD BOUND Program at Metropolitan State University of Denver must take responsibility for their academic success during both the academic year and the summer TRiO UPWARD BOUND Component. Because parental involvement and support is critical to a student s success, participation in TRiO UPWARD BOUND is really a family activity. The family needs to understand that TRiO UPWARD BOUND is a college preparatory program that operates year round to provide ongoing personal and educational assistance to students. As a TRiO UPWARD BOUND participant, I commit myself to the following: 1. Attend all my regular high school classes daily. 2. Attend all after-school TRiO Upward Bound academic classes daily, completing all my required class work, until I graduate from high school. 3. Attend all required tutoring and homework assistance sessions. 4. Be enrolled in advanced course work in my high school each semester that will make me eligible for admission to institutions of post-secondary education. 5. Demonstrate academic progress in all my classes and in efforts to increase my Grade Point Average (GPA). 6. Meet regularly with TRiO UPWARD BOUND administrative staff to complete assessments. 7. Complete any monthly assignments, forms, or career inventories given by TRiO UPWARD BOUND staff to assist in my preparation for entrance into a college or university. 8. Understand that my best performance is expected on all testing in the program, as well as on state standardized tests. 9. Attend all TRiO UPWARD BOUND activities during the school year. 10. Attend the six-week summer component held on the Auraria campus, participating fully in all activities. 11. Conduct myself in an appropriate manner at all times, demonstrating respect for others, and above all, respect for myself. 12. My goal is to enroll and complete a postsecondary education. Students who fail to comply with the student responsibilities or with the Goals and objectives on this Contract, may be placed on probation or suspended from the TRIO UPWARD BOUND Program. We have read the above stated student responsibilities and agree to jointly work toward successfully completing the goals of high school graduation and college enrollment. As a parent, I will encourage my child to fulfill their commitment to Upward Bound. Student Signature Parent/Guardian Signature 8
Information Release Form To Whom it May Concern: We grant the TRiO Upward Bound Program at Metropolitan State University of Denver permission to access information concerning my academic and personal progress during my secondary and post-secondary school enrollment. This information may include written records (grade and progress reports; standardized test scores; attendance and behavioral reports, etc.) and oral discussions with teachers, high school counselors and college administrators. Student s name (please print): Student s signature: : Parent/Guardian name(s) (please print): Parent/Guardian signature(s): : (A copy of this signed release will be sent to your high school records clerk, and may also be sent to the post-secondary institution you attend) TRiO Upward Bound (303) 556-2812 Campus Box 66 P.O. Box 173362 Denver, Colorado 80217-3362 fax :(303) 556-2516 9
Target School Recommendation TEACHER RECOMMENDATION At least one recommendation must be from the instructor of a core class (reading, writing, math or science). The applicant must have been a student in this instructor s class for at least one semester. Please feel free to submit other recommendations in addition to the one required. Name of applicant: Name of instructor: Class: How long was this applicant a student in your class? Attendance: Excellent Good Fair Poor Level of motivation in your class: High Average Low Comments: Were assignments generally turned in on time? Yes No Average grade on assignments: What specific skills (if any) need to be supported? Is this student strongly motivated in any particular subject? Please comment on this applicant s relationship with his or her peers and other adults: Are you aware of anything that would hinder the applicant from his or her educational goals (e.g., negative home environment, financial problems, etc.)? Other comments: 10
Target School Information COUNSELOR INFORMATION Please attach copy of student s transcript. Applicant Name: Counselor's Name: Current class size: Student s current class ranking: Applicant's GPA: as of Check area that best describes this applicant's program: Work Force General Other (type) College prep Applicant's Attendance Record: Poor Fair Excellent Is this student outstanding in any academic area? Non-Academic? If so, please elaborate: Are there any home or personal problems that may affect this student's progress? If so, please elaborate: If the student is lacking credits, please list courses and credits needed: Please list the standardized tests this student has taken, and include scores (e.g., State Assessment, PLAN, Explore, PSAT and benchmark scores, etc.): Please list standardized tests this student did not attain proficiency: GENERAL COMMENTS: 11