The Ohio State University 314 Hale Hall 154 West 12 th Avenue Columbus, Ohio 43210 614.292.2344 (Voice) 614.292.4798
The Ohio State University Upward Bound Program The mission of The Ohio State University Upward Bound Program is to instill and foster the necessary skills, talents and motivation needed for each participant to successfully graduate from high school, enroll in and complete their postsecondary education. Each student will be encouraged to take full advantage of their Upward Bound experience while continuously improving their level of preparation for the next stage in their academic career. The Upward Bound Program is intentionally designed to empower students to take a proactive role in their education.
The Ohio State University Upward Bound Program Application for Admission Please print or type Date Grade School Name of Counselor If 8 th Grader, Indicate School of Choice For Next Year: Program Of Study: College Preparatory General Vocational Special Education First Name MI Last Name Home Address City State Zip Home Telephone Number Cellular Telephone Number ( ) - ( ) - Email Address Parent/Guardian Email Address SOCIAL SECURITY NUMBER BIRTHDATE GENDER Male Female Are You A U.S. Citizen? If No, Visa Type: Yes No Do You Have Any Disabilities or Conditions That Require Special Attention? Yes No (If yes, please explain. Upward Bound reserves the right to request further documentation.) Do You Currently Participate In Any Other TRiO Sponsored Program? Yes No Have You Taken The Ohio Graduation Test? Yes No If Yes, which parts have you passed? Writing Reading Mathematics Citizenship Science *If applicable, please attach a copy of your latest Ohio Graduation Test Scores to this application.
PARENT INFORMATION TO BE COMPLETED BY PARENT OR GUARDIAN PARENT(S) CURRENTLY LIVING WITH STUDENT: Mother Father Both Other (Please indicate name of person(s) if other than your legal mother or father) Cultural Identification, please select one of the following: American Indian / Alaskan Native Black / African American Asian / Pacific Islander Hispanic / Latino White Native Hawaiian / Other Pacific Islander Biracial / Multiracial PARENT(S) OR LEGAL GUARDIAN(S) INFORMATION: (Mother or Guardian s) First Name Last Name Home Address City State Zip Social Security Number Home Telephone Number Cellular Telephone Number ( ) - ( ) - College Degree? Yes No IF YES, CHECK DEGREE(S) RECEIVED: Associate Bachelor Master Doctorate Please indicate place of employment: Work Telephone Number: ( ) - Title of Position: Fax Number: ( ) - Annual Salary: Email Address: PARENT(S) OR LEGAL GUARDIAN(S) INFORMATION: (Father or Guardian s) First Name Last Name Home Address City State Zip Social Security Number Home Telephone Number Cellular Telephone Number ( ) - ( ) - College Degree? Yes No IF YES, CHECK DEGREE(S) RECEIVED: Associate Bachelor Master Doctorate Please indicate place of employment: Work Telephone Number: ( ) - Title of Position: Fax Number: ( ) - Annual Salary: Email Address:
UPWARD BOUND RECOMMENDATION FORM TEACHER TO BE COMPLETED BY A PRINCIPAL, COUNSELOR, OR TEACHER (PLEASE SENT WITH TRANSCRIPTS, WHICH SHOULD INCLUDE ALL GRADES, STANDARDIZED TEST SCORES and ATTENDANCE RECORDS). Please complete and send directly to: The Ohio State University Upward Bound Program 314 Hale Hall 154 West 12 th Avenue Columbus, Ohio 43210 (614) 292-2344 The Upward Bound application for admission will not be processed without this form. has applied for admission to the Upward Bound Program. Please check the rating that best describes his or her character. 1 Mental Abilities 2 Academic Achievement 3 Interest in Academic Work 4 Perseverance 5 Social Behavior 6 Emotional Stability 7 Outlook on Life 8 Physical Health 9 Cleanliness & General Appearance 10 Interest in Attending College How long have you known the student? Excellent Very Good Good Fair Poor In what capacity? Based on your interactions with this student do you feel that he/she would apply to, be accepted, and enroll in college without the assistance of The Upward Bound Program? Does the student have any emotional/behavioral problems that require professional intervention? Do you recommend this student for Upward Bound? Why or Why Not? Reference Signature Name of School Street Address City ST Zip Telephone
UPWARD BOUND RECOMMENDATION FORM COUNSELOR TO BE COMPLETED BY A PRINCIPAL, COUNSELOR, OR TEACHER (PLEASE SEND WITH TRANSCRIPTS, WHICH SHOULD INCLUDE ALL GRADES, STANDARDIZED TEST SCORES and ATTENDANCE RECORDS). Please complete and send directly to: The Ohio State University Upward Bound Program 314 Hale Hall 154 W. 12 th Avenuue Columbus, Ohio 43210 (614) 292-2344 The Upward Bound application for admission will not be processed without this form. has applied for admission to the Upward Bound Program. Please check the rating that best describes his or her character. Excellent Very Good Good Fair Poor 1 Mental Abilities 2 Academic Achievement 3 Interest in Academic Work 4 Perseverance 5 Social Behavior 6 Emotional Stability 7 Outlook on Life 8 Physical Health 9 Cleanliness & General Appearance 10 Interest in Attending ATTENDANCE College (Please provide attendance date for current and previous school year): Current Year Previous Year Times Absent Times Tardy Do you recommend this student for Upward Bound? Why or Why Not? Reference Signature Name of School Street Address City State Zip
PARENT OR GUARDIAN INCOME VERIFICATION FORM Parent(s) or Guardian s Name Parent(s) or Guardian s Social Security Number Parent(s) or Guardian s Annual Income Applicant s Name Applicant s Social Security Number List all siblings who are living with the applicant Total income of all family members for the past year How many members of your household are supported by this income? Source of income: ADC Social Security Supplemental Security Workers Compensation Child Support Employment SIGNATURE OF PARENT(S) OR GUARDIAN(S) DATE YOUR APPLICATION CANNOT BE PROCESSED WITHOUT THE FOLLOWING INFORMATION: A copy of last year s Income Tax Form, OWF, Food Stamp or Medicaid benefits documentation, Social Security/Supplemental Security Benefits Letter, or Worker s Compensation benefits letter, and your son/daughter s most recent report card.
I hereby give my permission for MEDICAL EVALUATION TO BE COMPLETED BY A PARENT OF GUARDIAN To receive medical and/or dental services at The Ohio State University Student Health Services Center or at the nearest hospital during the time he/she is participating in activities sponsored by the Upward Bound Program at The Ohio State University. I understand that these services must be covered by my insurance policy. Upward Bound or The Ohio State University does not pay for medical or dental services. Parent of Guardian s Signature Date Student s First Name Middle Initial Last Name Emergency Contact Name(s): Emergency Phone #: Alternative Emergency Phone #: Social Security Number - - Birth Date - _ - Gender: Male Female Home Address: City, State, Zip Please list any special contact instructions: MEDICAL INFORMATION Have you ever been hospitalized? YES NO If yes, indicate the reason: Are you on any medication? YES NO If yes, what? Indicate any current medical problems and the appropriate method of treatment: Indicate any special instructions should a medical emergency occur: Name of family physician, clinic and/or hospital: Please list any known allergies to medication, food or any other allergens: Is there any other information which will help us to meet your child s medical needs? If yes, please describe:
STUDENT QUESTIONAIRE AND AGREEMENT FORM 1. What are your career goal(s)? 2. Why is attending college important to you? 3. Why do you desire to become a member of The Ohio State University Upward Bound Program? 4. Please rate the importance of the following statements on a 5 point scale. (1) being not important, (2) being somewhat important, (3) being neutral, (4) being important, and (5) being very important I need to improve my grade point average. I need to improve my achievement test scores. (Ohio Graduation Test, ACT, SAT) I need more opportunity and encouragement to take college preparatory courses. I am unsure of my career goals and need more information on careers. I need to improve my use of the English language. I need to have more confidence in my abilities. I need to understand, accept and like myself better. I need to improve how I interact with others socially. I need to improve my behavior in the classroom. I need to become a more disciplined person in regards to my school work. Student Agreement: I understand that if I am accepted into The Upward Bound Program at The Ohio State University, I will agree to: 1) Attend all Upward Bound meetings during the year ; 2) Attend the six week summer program each year ; 3) Attend and take part in all Upward Bound activities; 4) Abide by All rules and regulations of the Upward Bound Program; 5) Develop myself fully for graduation from high school and college. Signature Date
PARENTAL RELEASE AND AGREEMENT FORM Permission to Release: I hereby grant permission for my child, to participate in The Ohio State University Upward Bound Program if he/she is selected. I also give my child permission to participate in all programs and activities, including the summer academic camp, and travel on all Upward Bound sponsored activities in vehicles and other modes of transportation paid for or supplied by The Ohio State University Upward Bound Program. In consideration of the activities provided for my child, I hereby release The Ohio State University, Upward Bound, and their employees from any claims for injury or damages arising out of my child s participation. I also accept responsibility for my child s conduct while participating in Upward Bound, and release The Ohio State University and Upward Bound from liability from injuries or damages resulting from my child not following and adhering to program policies. Permission for Release: I hereby grant permission for The Ohio State University Upward Bound Program to have access to and receive copies of my child s academic records. And in accordance to federal mandates, I hereby grant permission for The Ohio State University Upward Bound Program to have access to and receive copies of my student s academic record through post-secondary education. I understand that the U.S. Department of Education requires this information to determine the overall effectiveness of the Upward Bound Program. Parental/Guardian Agreement: I, the parent/guardian understand that my son/daughter upon being accepted into The Ohio State University Upward Bound Program will attend weekly tutorial sessions during the school year (Oct/May) and will participate in a non-residential academic summer camp. My son/daughter will continue the program until the final summer after their graduation from high school. I understand that while in the Upward Bound Program, my son/daughter will receive instruction in the academic skills necessary to aid him/her in completing a college preparatory program and continuing their education in college. I understand that Upward Bound will provide information about scholarships, grants, and loans, which will aid him/her in securing a college education. However, I realize that the Upward Bound Program does not provide college funding. I will support the Upward Bound Program by supporting the rules and regulations of the program and encouraging my child s active participation in all activities. I also agree to participate actively in the Upward Bound Program s parent activities. I further understand that if my child does not participate in Upward Bound activities they forfeit their right to participate in the program. Print Parent or Guardian Name Date Signature of Parent or Guardian Print Student Name Date Signature of Student
MINOR STUDENT MEDIA RELEASE I, parent/guardian of, a minor student of The Ohio State University Upward Bound Program, do hereby give permission to The Ohio State University Upward Bound, to use my child s photograph or photographic image, name, birth date, honor roll information and voice recordings in official OSU Upward Bound business, including: OSU web sites, newsletters, newspapers, videos, and other print and electronic materials as deemed appropriate by OSU Upward Bound Staff. It is agreed that the use of any photograph or photographic image of our students shall in no way be used in any other forum other than for official University / Upward Bound business. In consideration of my child s engagement as a model and for other good and valuable consideration herein acknowledged as received, I hereby grant The Ohio State University and assigns, those acting with its authority and permission, the irrevocable and unrestricted right and permission to copyright, in its own name or otherwise, and use, re-use, publish, and re-publish photographic portraits or pictures of my child or which my child may be included, in whole or in part, or composite or distorted in character or form, without restriction as to changes or alterations in conjunction with my child s own or fictitious name, or reproductions thereof in color or otherwise, made through any medium at his studios or elsewhere, and in any and all media now and hereafter known for illustration, promotion, art, editorial, advertising, trade, or any other purpose whatsoever. I also consent to use of any printed matter in conjunction therewith. I hereby waive any right that I may have to inspect or approve the finished product and the advertising copy or other matter that may be used in connection therewith or the use of which it may be applied. I hereby release, discharge, and agree to save harmless The Ohio State University and assigns, and all persons acting under its permission or authority or those for whom acting from any liability by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form, whether intentional or otherwise, that may occur or be produced in the taking of said picture or in any subsequent processing thereof, as well as any publication thereof, including without limitation any claims for libel or invasion of privacy. I do hereby release, acquit and forever discharge the State of Ohio, The Ohio State University, its officers, employees, attorneys, representatives, insurers, and assigns from any and all demands, cause of action and/pr judgments of whatsoever nature of character, past or future, known or unknown, whether in contract or in tort, whether for personal injuries, property damage, payments, fees, expenses, accounts receivable, credit, refunds, or any other monies due or to become due, or damages of any kind or nature, and whether arising from common law or statute, arising out of, in any way, the use of my child s photograph, photographic image, name, birth date, honor roll information and voice recordings for official University business. This release contains the entire agreement between the parties and shall be binding upon and inure to the benefit of the successors and assigns of the undersigned. Date Minor s Signature Parent/Guardian Signature Print Name
Application Checklist Please Make Sure That Each Item Is Complete and Mailed With Your Application Most Recent Report Card Ohio Graduation Test Scores (If applicable) Teacher Recommendation (To be mailed separately by teacher) Counselor Recommendation (To be mailed separately by counselor) Income Verification Documentation (Example: Income Tax Form, Food Stamp or Medicaid Documentation, OWF, etc.) Medical Evaluation Parental and Minor Student Release Form Please Forward All Application Materials To: The Ohio State University Upward Bound Program 314 Hale Hall 154 W. 12 th Avenue Columbus, Ohio 43210