2015-2016 Student Application Packet
GUIDELINES ON HOW TO APPLY:
The Student Application Packet has several parts: (please use an ink pen to fill out)
-- Student Application Form which student and parent complete (3 pages)
--Parent Information Document which parent or legal guardian complete (2 pages)
--School Information Form and Student Recommendation Form which school personnel
complete (2 pages)
AND, the following are completed by both the student and the parent or legal guardian:
--Authorization to Provide Grade Reports and Student Records
--Parent/Student Contract
--Photograph, Video, Audio and Swimming General Release Form
A program description, statement of confidentiality and the Student Rules and Regulations/Policies and Procedures
(based on grade) of Upward Bound are also included in the packet for review and for your records. It is
important that the proper signatures are completed by the required individuals wherever indicated on the
forms. Failure to provide signatures will delay the application process and lessen the chances for a student
to be accepted!
 Parents or legal guardians must provide a form of family income documentation. This documentation may
include, but is not limited to:
1) A 1040 Tax Form from the most recent year available.
2) Documentation of Low Income Status form (attached).
3) Verifiable evidence of State Assistance being provided and the annual amount.
 A student applying to Upward Bound must provide a short, one paragraph statement about his or her high
school and post-secondary interests. Space is provided on the Student Application Form (please reference #19
Student Statement) for this purpose. Applications lacking this information will not be reviewed.
 The student must have his or her school counselor, teacher, or principal complete the Student Recommendation
Form. This form addresses the applicant's strengths/weaknesses and potential for success in an intensive
precollege program. An application is not complete until the Student Recommendation Form is provided to
Upward Bound. A student may wish to submit additional letters of recommendation as well. Incomplete
Student Applications will not be selected for interview.
 The school representative completing the School Information Form should be sure to complete all parts of the
form to the best of his/her ability. Upward Bound uses all information provided in assessing the applicant's
needs, academic success and potential. The school representative also needs to attach a recent copy of the
applicant's school transcript including, Standardized test scores. An application is not complete without
a school transcript.
PLEASE REMEMBER! THAT AN APPLICATION IS NOT FULLY COMPLETE UNTIL ALL FORMS
IN THE APPLICATION PACKET, INCLUDING INCOME DOCUMENTATION, TRANSCRIPTS, AND
STUDENT RECOMMENDATION FORM, ARRIVE IN THE UPWARD BOUND OFFICE.
10/2015
The Upward Bound Program has been hosted by the University of Wisconsin-Stevens Point for 47 years.
All participants are from households which are considered low-income and/or where neither parent has completed
a four year college degree. Students are recruited from nine target high schools in the seven counties of Portage,
Wood, Vilas, Lincoln, Waushara, Marathon and Oneida, which consists of small towns, reservations and rural
areas. Eligible students must reside in the target area and attend a target school.
Students may apply for the Upward Bound Program while in the eighth grade, but before entering the
twelfth grade. First consideration is given to those students demonstrating motivation and meeting both lowincome and first generation requirements. All participants are given the opportunity to renew their enrollment in
Upward Bound each year before any new students are selected to fill vacancies. The admissions process to
Upward Bound is competitive and there are more applicants than vacancies due to budgetary restrictions. Upward
Bound encourages students to remain in the program until graduation from high school. Formal involvement with
Upward Bound ends when a student completes 12th grade and has been enrolled in a college, university or degree
granting technical school of their choice. Typically 90% of Upward Bound graduates immediately go to college.
All aspects of the Stevens Point Upward Bound Program are aimed to help students learn to feel comfortable
in an academic setting, discover their potential, graduate from high school and complete a college education. To
this end, Upward Bound conducts a 6 week summer component on the UWSP campus each year for freshmen,
sophomores, juniors and seniors. Due to limited funding, only 60 students are selected to participate in the annual
summer component. During the summer component, students enroll in classes designed to stimulate interest,
enhance basic skills and to review varied subject matter. Small class sizes provide individualized instruction and
many innovative methods are used which assist students to become actively involved in the learning process to
experience academic successes. Upward Bound students participate in a variety of educational, cultural and
recreational activities (for example, guest speakers, visits to museums, bowling, intramural sports, etc.). Students
reside in a campus residence hall, supervised by a hall director and live-in chaperones. The summer component is
a very involved, intensive seven day a week experience.
Each September, Upward Bound staff evaluates each student's social and academic progress for the summer
component. This evaluation process culminates with a Credit Recommendation being prepared by the Program
Director and sent to the student's high school and parents. All target high schools grant Upward Bound students
credit for their summer component work. The Program stresses academics first and foremost. Other activities are
scheduled around required course work.
During the school year, Upward Bound students must participate in program activities, have good school
attendance, work for better grades, and study outside of regular class hours. Monthly activity reports are required
from students so Upward Bound Program staff may maintain contact and provide any needed support. Weekend
workshops designed to reinforce academic skills and attitudes are held each fall and spring. These workshops also
provide students and summer staff with the opportunity to reunite and renew friendships. Upward Bound staff
provide counseling, tutoring, and mentoring at students' schools on an average of twice per month.
Upward Bound at UW-Stevens Point is a twelve month academic program that strives to provide more than
just classroom skills. The emphasis is on the improvement of individual academic attitude and ability leading to
the Upward Bound goal of providing students the knowledge, confidence and fortitude for post-secondary entrance
and success at the college of their choice.
10/2015

STUDENT APPLICATION FORM
Complete all items on this application. Only students whose goal is to obtain a 2 or 4 year college degree need
apply. Please print.
1. NAME: ______________________________________________________________________
(last)
(first)
(middle)
2. SEX: _____ Female
_____ Male
3. SOCIAL SECURITY NUMBER: ________-_____-________ Required
4. BIRTH DATE: _______________________________
(month/day/year)
5. BIRTH PLACE: __________________________________________
6. HOME ADDRESS: _______________________________________________________________
(route or house number)
(box number or street)
________________________________________________________________
(town or city)
(county)
(state)
(zip code)
STUDENT’S SCHOOL E-MAIL ADDRESS: ______________________________________________
7. PARENTS’ NAMES: __________________________________________________________
(father)
(mother)
(last)
8. HOME PHONE: (_____) ____________ PARENT/GUARDIAN: (_____) ________________
area code/number
WORK PHONE:
area code/number
9. ETHNIC/RACIAL BACKGROUND (check one or more):
White
Asian
Hispanic
10.
LANGUAGE SPOKEN AT HOME: _____ English
11.
WITH WHOM DO YOU LIVE?
Black
American Indian
Pacific Islander
_______________________________ Other
____Parent(s)
____Other Relative-Relationship: ____________________
____Foster Parents ____ Other Specify: ___________________
School Information
12.
CIRCLE THE HIGHEST GRADE YOU WILL HAVE COMPLETED BY JUNE 2016:
8th
9th
10th
11th
13.
SCHOOL YOU ARE NOW ATTENDING: ___________________________________________
(school name)
10/2015
Page 2 (Student Application Form)
14.
WHAT LEADERSHIP OR EXTRACURRICULAR ACTIVITIES HAVE YOU PARTICIPATED IN?
_____________________________________________________________________________
15.
DO YOU WANT TO ATTEND COLLEGE WHEN YOU GRADUATE FROM HIGH SCHOOL?
Yes
No
Health Information
16.
ARE THERE ANY PHYSICAL ACTIVITIES YOU SHOULD NOT TAKE PART IN? Yes
No
If answer above is “YES,” please explain: _____________________________________________
__________________________________________________________________________________
17.
PLEASE EXPLAIN ANY PLANS YOU HAVE AFTER GRADUATION FROM HIGH SCHOOL:
__________________________________________________________________________________
__________________________________________________________________________________
18.
HOW DID YOU LEARN ABOUT UPWARD BOUND (Source)? __________________________
STUDENT STATEMENT (IS REQUIRED!) IF NO STATEMENT, THEN NO INTERVIEW
19. IN THE SPACES PROVIDED, PLEASE PROVIDE US WITH A STATEMENT THAT WILL DESCRIBE YOUR
PERSONAL EDUCATIONAL GOALS, YOUR ACADEMIC STRENGTHS AND WEAKNESSES AND HOW
YOU FEEL UPWARD BOUND WILL HELP ACHIEVE THEM. ALSO, INCLUDE ANY PERSONAL
CHARACTERISTICS OR SPECIAL CIRCUMSTANCES THAT UPWARD BOUND SHOULD KNOW ABOUT.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
(Attach an additional sheet, if necessary)
(Student Application Form) Page 3
20. STUDENT RECOMMENDATION FORM: Before any student can be considered for Upward Bound,
applicants must obtain a STUDENT RECOMMENDATION from one of the following: teacher, counselor, or
principal. This form should be attached to and sent along with the SCHOOL INFORMATION FORM,
SCHOOL STUDENT TRANSCRIPT, AND WISCONSIN KNOWLEDGE AND CONCEPTS EXAMINATION (WKCE) test
scores to Upward Bound.
21.
WHICH AREAS BELOW DO YOU NEED HELP WITH? (Check all that apply.)
_____ Career Planning
_____ College Information
_____ Financial Aid Planning
_____ Class Scheduling in School
_____ Study Skills Improvement
_____ ACT Preparation
_____ Test Taking Skills
_____ Below Proficient on Standardized Tests
_____ Preparing for College
_____ Being More Motivated
_____ Isolated Where You Live
_____ Lack of Help With Selecting
College Prep Courses
_____ Other: _________________________
_____
_____
_____
_____
_____
_____
_____
_____
_____
Self-Image
Listening Better in Class
English (Written and Spoken)
Mathematics
Science
Better Reading Skills
Speech
Learning Disability Accommodations
Learning About Places Other Than
Where You Live
_____ Learning About Students Who
Are Different From Yourself
_____ Making Friends
22.
SIGNED: ________________________________________________ DATE: ____________
(Signature of Applicant)
23.
SIGNED: ________________________________________________ DATE: ____________
(Signature of Parent)
COMPLETE all items on the Student Application. Then, return:
Page 1
Page 2
Page 3
Page 4
Page 5
Page 6
Page 7
STUDENT APPLICATION
PARENT INFORMATION DOCUMENT
BE SURE TO ATTACH INCOME DOCUMENTATION
SCHOOL INFORMATION FORMS
BE SURE TO ATTACH TRANSCRIPTS & WKCE TEST SCORES SCHOOL
AUTHORIZATION TO PROVIDE GRADE REPORTS AND STUDENT RECORDS
PARENT/STUDENT CONTRACT
UWSP CAMP HEALTH FORM
PHOTOGRAPH, VIDEOTAPE, AUDIOTAPE and SWIMMING RELEASE FORM
as soon as possible to Upward Bound.
MAIL TO 
UPWARD BOUND
204 Nelson Hall
University of Wisconsin - Stevens Point
Stevens Point, WI 54481-3897
NOTE: An application is not complete until all forms (Parent, Student, School), Authorization to
Provide Grade Reports/Student Records, Annual Student Contract, Release Forms with a Student
Recommendation have arrived in the Upward Bound Office. Every item on each form must be
correctly filled out!

PARENT INFORMATION DOCUMENT
This document must be completed by a parent, guardian, or other adult legally responsible for the
applicant. The information requested is necessary to determine eligibility for Upward Bound.
Information is and will be kept confidential.
1. STUDENT’S FULL LEGAL NAME: ____________________________________________________
(last)
(first)
(middle)
2. Is the student your natural-born or a foster child? _____________________________________
NOTICE: Federal regulations require Upward Bound applicants to include a copy of their
parent/guardian(s) Federal 1040 Tax Statement OR the attached “Documentation of Low Income”
form. Upward Bound CANNOT process applications without this information.
3. TAXABLE FAMILY INCOME as reported on Federal Tax Forms for the last calendar year. If no return
was filed, please estimate income:
$_______________________
4. Please estimate TOTAL FAMILY INCOME for the current year:
$_______________________
5. Please check all items below that apply to the student, family, or to both:
Student
Family
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
Need
Lives in federal or state supported low-income housing
Lives on an Indian Reservation
Lives on an operational farm
Could be classified as migrant
Is on a federally or state supported assistance program
Has English as a second language
Lives in an area of geographic or cultural isolation
Only one parent living at home
Head of household is unemployed or in low-income/dead-end job
Has a learning disability (including information on parents and
children)
6. Below please complete information on adult (ex. parents, guardians) household occupants:
(If more space is needed, attach a separate sheet).
Name
Relationship to Student
Age
________________________________
______________________________________
____
________________________________
______________________________________
____
________________________________
______________________________________
____
PLEASE ATTACH INCOME DOCUMENTATION
TO THIS FORM (EITHER 2014 TAX RETURN OR
“ DOCUMENTATION OF LOW INCOME STATUS” FORM.)
*Students who are both Low Income and
First Generation in status have the best
chance for admission to Upward Bound.
10/2015
Page 2 (Parent Information Document)
7. Below please list all children in the family, including those not presently living at home:
(If more space is needed, attach a separate sheet).
Age
Name
_____
_____
_____
_____
_____
_____
School Attending
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
Grade
_____
_____
_____
_____
_____
_____
8. Are you willing/able to attend an orientation session?
Yes ____ No ____
If No, please provide reason: ____________________________________________________
9. PARENT’S LEVELS OF EDUCATION: Please state the highest level of education achieved.
Mother: ________________
Father: _________________
Legal Guardian: ____________
Applicants will not be excluded from Upward Bound because of health or social factors, but the Director
should be aware of any special conditions that are present to be better meet student needs.
10.
Are there any physical activities (swimming, running, etc.) which applicant should NOT take part in?
________________________________________________________________________________
________________________________________________________________________________
11.
Please describe any emotional/psychological concerns that should be addressed when working with the
participant: ___________________________________________________________________
_______________________________________________________________________________
12.
What EDUCATIONAL benefits would you most like to see your son/daughter receive from his/her
participation in Upward Bound? ______________________________________________________
________________________________________________________________________________
13.
Does your son/daughter have a learning disability?
Yes ____
No ____
14.
Will the Upward Bound summer component June 19–July 26, 2016 interfere with any planned family travel,
work or other activities? If so, please explain:
________________________________________________________________________________
________________________________________________________________________________
15.
Parent e-mail address: __________________________________________
Your signature below will certify as to the truth of the statements made on this document and will also serve as an
authorization for Upward Bound to request and receive information from the applicant’s school and medical
facilities where such records are kept.
PARENT OR LEGAL GUARDIAN
SIGNATURE: _________________________________________
DATE: ________________
Relationship to Applicant: __________________________________
COMPLETE ALL ITEMS ON BOTH SIDES OF THIS DOCUMENT. RETURN THIS WITH THE STUDENT
APPLICATION FORM, RELEASE FORMS, AND ATTACHED INCOME DOCUMENTATION TO: Upward
Bound, 204 Nelson, University of Wisconsin-Stevens Point, WI 54481-3897.
Documentation of Low Income Status
Name of Applicant: _________________________
Total Number of Household Members: ___________
I attest that our household’s taxable income for the previous tax year fell within the
established federal low income guidelines as outlined below:
Federal TRIO Programs
Current-Year Low-Income Levels
(Effective January 28, 2015 until further notice)
Size of Family Unit
48 Contiguous States,
D.C., and Outlying Jurisdictions
Alaska
Hawaii
1
$17,655
$22,080
$20,325
2
$23,895
$29,880
$27,495
3
$30,135
$37,680
$34,665
4
$36,375
$45,480
$41,835
5
$42,615
$53,280
$49,005
6
$48,855
$61,080
$56,175
7
$55,095
$68,880
$63,345
8
$61,335
$76,680
$70,515
For family units with more than eight members, add the following amount for each additional family
member: $6,240 for the 48 contiguous states, the District of Columbia and outlying jurisdictions; $7,800 for
Alaska; and $7,170 for Hawaii.
The term "low-income individual" means an individual whose family's taxable income for the preceding
year did not exceed 150 percent of the poverty level amount.
The figures shown under family income represent amounts equal to 150 percent of the family income
levels established by the Census Bureau for determining poverty status. The poverty guidelines were
published by the U.S. Department of Health and Human Services in the Federal Register on January 22,
2015.
Parent/Guardian Signature: _____________________________
Date: ____________
This form MUST be returned to Upward Bound, 204 Nelson Hall, UW-Stevens
Point, Stevens Point, WI 54481 in lieu of a copy of an income tax return. An
applicant’s application is NOT complete until a form of income documentation is
on file in the Upward Bound Program office.

SCHOOL INFORMATION FORM
To be completed by the Guidance Counselor or Teacher at the school the applicant is now attending.
School background is needed to determine student eligibility. Information will be kept confidential, but
must be on file.
Note: a 2.30 is required for Freshmen and Sophomores and 2.60 for Juniors for Program Entry.
1. STUDENT’S FULL LEGAL NAME: _______________________________________________
(last)
(first)
(middle)
2. SCHOOL NAME: _____________________________________________________________
3. SCHOOL’s Upward Bound Contact TELEPHONE and E-MAIL: _________________________
_________________________
4. What federal qualification(s) does this student meet as listed below (check all that apply):
______ Low Income (see Federal TRIO Program Low Income Levels)
______ 1st Generation (Either parent does not hold a bachelor’s degree)
______ Both Low Income/1st Generation with post-secondary potential
______ Has a documented learning disability
5. Please circle the highest grade the applicant will have completed by June:
8th
9th
10th
11th
6. Does student have any post-secondary plans that you are aware of?
Yes
No
If “Yes”, please explain: ________________________________________________________
(program or major)
(school)
7. Student applicant’s Grade Point Average on a 4.00 scale? __________
UPWARD BOUND is a federally funded TRIO program designed to assist students who
demonstrate academic potential, motivation and seek to obtain a college degree.
NOTE: Check to see that all numbered items and Student Recommendation Form are
complete. Attach copies of School Transcripts, and Standardized Test Scores and
Return TO: Upward Bound Program, 204 Nelson, University of Wisconsin-Stevens
Point, Stevens Point, WI 54481-3897.
10/2015
Return to:
Upward Bound Program
204 Nelson Hall
University of Wisconsin-Stevens Point
Stevens Point, WI 54481-3897
Student’s Name ___________________________________________________________ Grade _____________
Name of Person Making Recommendation ________________________________ Position ___________________
To the student: This form needs to be completed by a teacher or counselor.
To the teacher/counselor: The Upward Bound Program is designed to prepare and motivate students with academic
potential for success in postsecondary education. Your evaluation of the nominee is extremely beneficial to us in
determining if the student will succeed in this highly intensive program. Please rate the student on each of the following
areas of personal competence. If you would like to add additional comments or special considerations on why this student
should be accepted, please feel free to continue on the back. Thank you!
Grasps fundamental ideas and concepts
 Above Average
 Average
 Below Average
 N/A
Integrates complex information
 Above Average
 Average
 Below Average
 N/A
Completes assignments, fulfills contracts
 Above Average
 Average
 Below Average
 N/A
Accepts criticism
 Above Average
 Average
 Below Average
 N/A
Assumes responsibility
 Above Average
 Average
 Below Average
 N/A
Is motivated to achieve
 Above Average
 Average
 Below Average
 N/A
Has good work habits; is disciplined
 Above Average
 Average
 Below Average
 N/A
Has positive sense of self
 Above Average
 Average
 Below Average
 N/A
Is sensitive to the needs of others
 Above Average
 Average
 Below Average
 N/A
Has foundation in basic skills
 Above Average
 Average
 Below Average
 N/A
Demonstrates leadership skills
 Above Average
 Average
 Below Average
 N/A
Is emotionally mature
 Above Average
 Average
 Below Average
 N/A
Student has potential for postsecondary
success
 Above Average
 Average
 Below Average
 N/A
For ESL Students only:
Compared to native English speakers in the same grade level, this student’s English WRITING skills are:
 Better
 Same
 Needing Improvement
Compared to native English speakers in the same grade level, this student’s English READING skills are:
 Better
 Same
 Needing Improvement
Signature ___________________________________________________
Date _______________
Please return this completed form to the University of Wisconsin-Stevens Point Upward Bound Program. Thank you.

This Authorization is in effect from the date signed until December 31, 2022.
ATTENTION Parents and Student:
When this form is completed send to the
Upward Bound Program.
AUTHORIZATION TO PROVIDE GRADE REPORTS AND STUDENT RECORDS
TO:
School Guidance Office and/or College/University Records Office
_____________________________________________________________
Student Name (please print)
I/We request that a copy of my Standardized test results and academic transcripts including:
1.
2.
3.
4.
5.
6.
7.
8.
Grades by Subject
Student Class Schedule
Attendance Records
Credits Earned
Grade Point
Class Rank
Personal Identification Information
Access to Skyward
To be released to the Upward Bound Program at the University of Wisconsin-Stevens Point.
_____________________________________________________________
Student's Signature
_____________________________________________________________
Parent's or Legal Guardian's Signature
(Parent/Legal Guardian must sign only if student is under 18 years of age)
______________________________
Date
ATTN: FOR SCHOOL OFFICIALS The Upward Bound Program at the University of Wisconsin-Stevens
Point requests that the above student's grade reports be sent to our office at the conclusion of
each marking period. WKCE test results and/or high school state assessments in
reading/language arts and math will be requested as necessary (see above). This information is
requested in compliance with the Office of Education requirements and in accordance with the
Student Rights Act of 1975. These documents are required to substantiate our federal grant’s
annual performance objectives. All records will be used by Upward Bound exclusively and not
disseminated in any way.
Send Student Records To 
Upward Bound Program
204 Nelson Hall
University of Wisconsin-Stevens Point
Stevens Point, WI 54481-3897

PARENT/STUDENT CONTRACT
I understand that Upward Bound is a year-round intensive educational/skill-building program. I,
as a student, am expected to make an honest and sincere effort to improve my academic skills,
participate in activities and be considerate of others. I will cooperate with the Upward Bound staff by
complying with any request asked of me. Parents are expected to attend events, as explained.
I have read the Student Rules and Regulations/Policies and Procedures and I agree to do
my very best to follow them. They are established to foster academic progress and promote my safety
and well being throughout the year. Further, I realize that if I have any doubt as to the meaning or
intent of these rules, I will ask Upward Bound Staff that they be explained to me.
As members of the Upward Bound Program we agree to all 11 items listed below.
We fully understand that our participation in the Upward Bound Program will be
canceled should we violate any of the following 11 requirements of student enrollment:
1. Not attending a summer component during the first year of enrollment.
2. Participating in additional summer components as required by the Program.
3. Attending scheduled school meetings with Upward Bound Staff.
4. Attending tutorial sessions, as required.
5. Attending Fall and Spring Workshops and summer component activities.
6. Participating in at least two (school year) College Campus Visits.
7. Participating in Parent/Participant Workshops – at least one each year (parents).
8. Submit Participant Activity Reports and complete other necessary paperwork such
as Renewals, etc.
9. Submit to illegal drug screening and alcohol testing, as requested.
10. Exhibit motivation towards school work and preparation for college.
11. Maintain minimal (or better) grade point averages (GPA) as required in all core
courses such as Reading, Writing, Math, Science and Foreign Language.
You must check item(s) appropriate to your program standing below:
____ Yes, as a NEW student to the program:
I WILL PARTICIPATE IN THE UNIVERSITY OF WISCONSIN-STEVENS POINT UPWARD BOUND PROGRAM.
I WILL MAINTAIN AT LEAST A “C” AVERAGE (2.30 OVERALL FOR FRESHMEN AND SOPHOMORES)
AND AT LEAST A “C+” AVERAGE (2.60 OVERALL FOR JUNIORS AND SENIORS).
I WILL PARTICIPATE IN THE 2016 SUMMER SESSION (JUNE – JULY, 2016, AS REQUIRED).
I WILL PARTICIPATE IN THE 2016-2017 ACADEMIC YEAR PROGRAM (September 1, 2016 through May 31, 2017).
OR
____ Yes, as a CONTINUING student:
I WILL PARTICIPATE IN THE UNIVERSITY OF WISCONSIN-STEVENS POINT UPWARD BOUND PROGRAM.
I WILL MAINTAIN AT LEAST A “C” AVERAGE (2.30 OVERALL FOR FRESHMEN AND SOPHOMORES)
AND AT LEAST A “C+” AVERAGE (2.60 OVERALL FOR JUNIORS AND SENIORS).
I WILL PARTICIPATE IN THE 2016 SUMMER SESSION (JUNE-JULY, 2016, AS REQUIRED)
I WILL PARTICIPATE IN 2016-2017 ACADEMIC YEAR PROGRAM (September 1, 2016 through May 31, 2017).
My signature below grants permission for the Upward Bound Program to receive the following:
(1) Records from my school such as grade reports, Standardized Test Results, class ranking; and
(2) From doctors or other medical personnel the report(s) of any examination, tests, injury, illness, or
treatments I have while in Stevens Point or participating in an Upward Bound Program sponsored
activity.
STUDENT SIGNATURE: ________________________________________Date: _____________
PARENT/GUARDIAN SIGNATURE: _______________________________Date: _____________

PHOTOGRAPH, VIDEO, AUDIO AND SWIMMING GENERAL RELEASE FORM
Photograph, Video and Audio Release
I fully understand and agree that the Upward Bound Program may take photographs, video
recordings and/or audio recordings of participants and activities. I agree that the University of
Wisconsin-Stevens Point Upward Bound Program shall be the sole owner of and may use
such photographs, videos and/or audio recordings relative to the promotion of Upward
Bound. I relinquish all rights that I may claim in relation to the use of said photographs,
videos and/or audio recordings.
Furthermore, I authorize the Upward Bound Program to audio record or video record any
meeting(s) or discussion(s) with my son/daughter or ward should they at any time become
involved in disciplinary proceedings. Audio and/or or video statements may also be made
from any and all Upward Bound students in regards to disciplinary proceedings and
accidents/injuries. Recording of such events shall be at the sole option of the Upward Bound
Program.
Swimming Release
I give my child permission to participate in waterfront activities while at a UWSP summer
camp. (Must check one)
 Yes
 No (check one)
My child does know how to swim:
 Yes
 No (check one)
My child’s swimming skill level is (check one):
 Beginner
 Intermediate
 Proficient
I have read and fully understand the above releases:
Parent/Guardian Name: ____________________________________________________________
(Please Print)
Parent/Guardian Signature:_________________________________________ Date: ___________
Street Address:___________________________________________________________
City:_________________________________State: ________ ZIP: _________
Student/Camper Name: ____________________________________________________________
Camp Name:Upward Bound Program
Attention Parents and Applicant:
Do NOT return this form to Upward Bound, this form is for your records.
PRIVACY ACT/CONFIDENTIALITY OF RECORDS
UPWARD BOUND PROGRAM
The following information deals with the Privacy Act and Confidentiality. It is imperative that this
legislation be enforced by all Upward Bound Program directors.
The personal information you give to the Upward Bound director is sent to the federal
government (Department of Education). The information given is protected by the
Privacy Act. No one may see the information unless they work with or for the Upward
Bound Program or are specifically authorized to see the information. The information
is necessary to determine if you are eligible to participate in the program and helps the
government to measure your success. The Department of Education has authority to
gather information to help make Upward Bound a better program (20 USC 1231a).
CONFIDENTIALITY OF INFORMATION
Great care is taken to make sure that the personal information collected on Upward Bound students is
kept confidential. Information or records relating to individual Upward Bound students or group(s) or
students who are participating or have participated in Upward Bound projects shall not be disclosed to
any person, group, agency, or organization without the express permission of the Director, Division of
Student Services, Veterans Programs, and the U.S. Department of Education. When a project or
contract terminates, all Upward Bound records in possession of the project or contractor shall be
disposed of only by the authority of and in accordance with procedures approved by the Director,
Division of Student Services and Veterans Programs.
In addition, any officer or employee of the United States or of any department or agency thereof who
publishes, divulges, discloses, or makes known in any manner or to any extent not authorized by law
any information coming to him in the course of his employment or official duties or by reason of any
examination or investigation made by, or return, report or record made to or filed with such
department or agency or officer or employee thereof, which concerns or relates to the Upward Bound
Program shall be subject to a fine of not more than $10,000 or imprisoned not more than one year, or
both, and shall be removed from office or employment under the provisions of Title 18, Section 1905
of the U.S. Code.
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UPWARD BOUND PROGRAM – UWSP
Student Rules and Regulations/Policies and Procedures
In order to have a smooth running program and provide for the well-being of all concerned, it is necessary to have rules for
student behavior. The Upward Bound Program at UW-Stevens Point expects its students to:
1.
2.
3.
4.
5.
6.
Be Responsible and Respectful
Defend Their Rights in a Socially Acceptable Manner
Maintain a Positive Academic Attitude
Attend Scheduled Events During the School Year and Summer-as applicable Parents and Students –
explained in the Parent/Student Contract
Display Academic Honesty in Completing Course Work
Respect and Obey Program Rules Designed for Safety and Academic Improvement.
Upward Bound students should know the following:

Use of alcohol and/or illegal drugs of any kind is not tolerated. Students caught in the possession of, association
with, or under the influence of such substances will be removed from the summer component and/or Upward
Bound activity immediately. The student(s) involved are dismissed from the program. See Alcohol and Illegal
Drug Use Policy.

Harassment and intimidation of other participants and/or the staff is strictly prohibited. Participants who verbally
or physically abuse other students and staff may be asked to leave the program. “Pranks” of any type are not
allowed and can result in immediate expulsion.

Throughout the academic year (school year), Upward Bound students are required to participate in program
activities, stay in school, make grades of "C+'s" or better, complete Participant Student Activity Reports, and
attend scheduled meetings both at school and as part of scheduled program activities.

As part of my preparation for college, I will attend at least 2 college campus visits during the school year offered
to me by Upward Bound during the course of my enrollment. These typically begin in the Spring of a student’s
sophomore year.

Students are required to turn in their Participant Activity Reports on time! Should a student not submit 2 or more
consecutive Participant Activity Reports they will be automatically dismissed from participation without prior
notice given, no exceptions will be granted.

Event Attendance: Students and parents are expected to attend sponsored events such as: Fall and Spring
Workshops, College Campus Visits, and Parent/Participant workshops as relevant. These events are important for
students and parents alike. Too often staff hear that “I had no knowledge of this”, “I do not understand”, “Why do
I/we have to do this?” “I have to work,” etc.
o
o
For parents: attending program events demonstrates to your student that preparing for college is
important!
For students: attending program events gives you the knowledge and power to be ready for college! You
learn nothing by not being there.
Summer Session:
1.
During summer session, students must be in their own assigned residence hall room by the specified time each
night and during the quiet study hour on designated evenings. Students must abide by the Cell Phone Usage
Policy.
Students may sign out to leave campus only when their classes are finished for the day and/or during regularly
scheduled free times. Students must officially "sign off campus" by indicating time leaving, destination, and
expected time of return. ALL off-campus sign-outs must be authorized by an Upward Bound staff member
(other than desk personnel). 2 hour sign-off maximum.
Parents are welcome to visit the program at any time, but it is advisable to call in advance to make sure your student
is not gone on a field trip or participating in a scheduled activity. Other visitors are allowed inside the lobby of the
hall only. Guests (non-family) and alumni must make their visits during visiting hours typically from 4:00-9:00
p.m., Monday through Friday, and are restricted to the lobby of the residence hall.
2.
All new students who are currently in the 9th, 10th or 11th grades are expected to complete the entire summer
component. Failure to do so may result in the dismissal of the student from the Upward Bound Program or loss of
credit. Should a student be absent 3 or more consecutive days for any reason without written permission from the
Program Director they will only be granted ½ credit for summer participation. New students are required to
attend the summer component, those who choose not to do so will be dismissed from Upward Bound.
3.
Weekends Home – Live-In students may spend a maximum of two weekends at home during the summer
component (emergencies excluded). Of the 2 weekends spent at home, the 4 th of July break must be one of the
two weekends; students may choose the second weekend, or not go home at all. Students will not receive full
credit for their Upward Bound participation if more than two weekends are spent at home or other places.
Parents/guardians are responsible for any expenses involved in the pick up and return of their Upward Bound
student. If anyone other than a parent or guardian is to transport the student, the Upward Bound Director must
have a written, signed permission slip stating who the student may go with and the expected time of return. Note:
A weekend begins Friday after all classes are over and ends Sunday evening at 7:30 p.m. See – Transportation.
4.
Part of the Upward Bounder's responsibility while on campus is the care and maintenance of his/her dormitory
room and the residence hall. Students are expected to keep the dorm rooms, lobby and basement area clean and
are responsible for any damages to the furnishings. The costs for screen repairs, lost keys or room damages will
be charged to the student’s parents. SMOKING IS NOT ALLOWED IN THE RESIDENCE HALL AND IS
ILLEGAL!
5.
Fireworks are never allowed in the residence halls or on campus.
6.
Privacy is respected. However, authorized personnel may enter your room for reasons of health, safety, general
welfare, or maintenance. You will always be given advance notice of any such action UNLESS there are
exceptional circumstances, such as safety, noise levels, or suspected items that are illegal.
7.
Upward Bound has an approximate student to staff ratio of 9 to 1 and provides adequate supervision for all
activities. However, students are encouraged to be independent. In all cases, students are expected to assume
responsibility for their actions.
8.
Disciplinary action for violations (4 Step Disciplinary Procedure) of Upward Bound Rules will vary according to
the circumstances (see Disciplinary Actions). Action taken will be much more severe where the health and safety
of others is involved. When infractions are repeated and no evidence of a desire to improve behavior exists, the
student will be expelled from Upward Bound permanently. All violations are subject to the 4 STEP DISCIPLINARY
PROCEDURE. THE PROGRAM DIRECTOR HAS FINAL AUTHORITY.
By following these guidelines, each Upward Bound student will derive maximum benefit from the Upward
Bound Program! Those who participate in the total Upward Bound Program will discover that their
involvement is a memorable, valuable experience that prepares one for success!
MISCELLANEOUS POLICIES AND PROCEDURES
The “I don’t want to be here clause”

Students, through their actions both verbal and/or nonverbal, may indicate to program staff that they do not wish to be
in the Upward Bound Program but are being “forced” to attend by parents, guardian, etc. In these instances the student
in question has 3 days to “change their attitude.” If change does not occur, residence hall staff can make a written
recommendation to the Program Director for that student’s permanent dismissal within 24 hours.
Not My Son or Daughter!

Unfortunately, a small group of students during their enrollment with the program, exhibit undesirable behavior or
academic difficulty. We understand that as parents or guardians you wish to believe that your child is not “at fault” in
these instances. It is asked that you as a parent or guardian work closely with staff to understand that yes, “your angel
at times can be human.” Students DO exhibit less than desirable behaviors in Upward Bound. We ask that you give us
the benefit of the doubt and respect that we are experienced professionals who will handle minor disciplinary issues
with your student in a positive & constructive manner. Thank you.
Transportation

Upward Bound provides transportation, as stated; to participants from home to Stevens Point at the beginning of
the summer component, during the 4th of July break and their return home at its completion. During the academic
year, all efforts are made to provide transportation for students to attend scheduled activities; however,
parents/guardians may have to furnish transportation when drivers and/or university vehicles are not available.
Camping Trip – during this event, students who choose not to participate must go home and provide their own
transportation. If the student has scheduled transportation home for this event and such transportation has not
arrived by the Camping Trip departure time, the student will be required to participate. All other transportation is
the responsibility of the parent or other authorized adult.
When Lodging at Hotels

When students are being lodged at hotels during Upward Bound events, they are expected and required to:
o Take care of the room provided to them and not abuse it – in any manner,
o Follow all hotel and Upward Bound rules – without question,
o Sleep only in their assigned room,
o Be equally responsible with other roommates for the care and condition of the room,
o Keep noise levels to a minimum.

Should any of the assigned students lodged in a room know of room abuse, “trashing,” or other misconduct by
another student in that same room, they MUST report it to a staff member BEFORE the room is vacated. If the
room is vacated and staff members are informed of room abuse at a later date, or by the hotel, the following will
occur:
o
All students lodged in the room that suffered abuse will be terminated from the Upward Bound program.
If one or more of the students in question reported the abuse before the room was vacated, a lesser
penalty will be administered to these students. NO EXCEPTIONS WILL BE MADE. Disrespect and
tarnishing the image of the Upward Bound program will not be tolerated!
Driver's Education and Non-Program Events

If a student decides to enroll in Driver's Education or elects to miss three (3) or more days of a summer component
for non-program events, the student will only receive a maximum of one-half credit for their summer participation.
Should a pattern of being absent from the summer component or summer component become apparent, program
termination can occur. Upward Bound should be your most important event.
Cell Phone Usage Policy

Students may utilize their cell phones between the hours of 8am to 8pm Sunday through Thursday and weekends
(the weekend begins a 4pm each Friday). Students who are “caught” using their phones for any reason during
Study Session, scheduled program events, college tours, guest presenters, etc. will, be given 1 warning, then if a
second subsequent violation occurs, the student will lose phone privileges for 1 week. Additional violations will
result in permanent phone loss for the duration of the summer or the student may choose to go home.

Students will not have access to their phones beginning with Student Orientation and the first 2 days of classes.

The above policy applies to any internet-capable device as well as phones.
Student Vehicles

Students have no need for an automobile in Stevens Point. If for some reason it is necessary for a student to bring
a vehicle to Stevens Point, it must be parked in a designated area and the keys must be left with the Residence Hall
Director or the Program Director. Students may not transport other students in their vehicles. Student vehicles
may not be used for any program purpose.
Valuables
 Students should not keep large sums of money on them or in their room while on campus. Upward
Bound cannot/will not be responsible for or reimburse students for cash that is misplaced, lost, or
stolen. Such valuables as stereos, televisions, computers, etc., should not be brought because
Upward Bound cannot cover replacement and/or repair costs if they are stolen or damaged while in
the student’s possession or control. Students must keep their door locked when not in their room.
Public Displays of Affections (PDA’s)
 Program educational goals far supercede “romantic relationships.” Such relationships are
exclusive in nature, detract a student from academics and are therefore detrimental to the Upward
Bound Program. Such relationships send the wrong message to parents and the public about
Upward Bound. Some examples of PDA’s include, but not limited to: making out, fondling,
caressing, etc. PDA’s of the type stated are not allowed during program operation! (“Holding
hands and brief good-bye kisses are not PDA’s.”)
Student Consequences:
Incident #1 – Verbal warning and meeting with Residence Hall Director.
Incident #2 – Both students suspended for 2 class days (sent home).
Incident #3 – Permanent termination from Upward Bound.
Medical Treatment

Treatment for accidental injuries is administered through the University Health Center or local hospital and paid for
by Upward Bound (coverage is primary on the first $7,500 of covered medical expenses). Students are encouraged
to have their own health insurance as limited accident insurance is provided by the university and only covers when
students are injured during a scheduled formal program activity or event (e.g., in class, field trip). However, if a
pre-existing injury or illness requires that a student seek medical attention at the local clinic or hospital, all medical
costs incurred will be the responsibility of the student's parent/guardian if not covered under the program's
Camp/Clinic Insurance Plan. Parents or guardians are informed of any serious health problems that occur while
their student is living in Stevens Point or participating in an Upward Bound activity. It is Upward Bound’s
responsibility to determine when a student needs treatment while they are involved in program activities.

NOTE: Parents will be sent original accident claim form and therefore parent is solely responsible for forwarding
original accident claim form with medical bills within 90 days of injury to name on top of the Accident Claim Form.
Physical Examinations

It is recommended that your student have a complete physical examination every two years. If your student has
had a physical examination during the past two years please forward a copy to Upward Bound.
Dehydration

During the summer component students need to drink water as often as possible to combat dehydration and “heat
stroke.”
Credit Recommendations

At the completion of the summer, a recommendation for credit is sent to both the student's parent/guardian and
home high school during September. A recommendation for FULL CREDIT, ONE-HALF CREDIT OR NO
CREDIT is advised based on a student’s academic and social performance.
Leaving Things Behind on Field Trips

Should a student leave behind personal articles while on a field trip and staff must return these articles, the student
will be fined. Fines will range from 5 to 10 dollars depending on the difficulty in returning the items (e.g., pickup, postage, etc.). Students are expected to be responsible for their personal belongings. “YOU BROUGHT IT,
YOU TAKE IT HOME!”
Please remember that Upward Bound tries to focus on the individual needs, desires, strengths and
interests of each participant. However, we have limitations and so must also regard the students as a
group and consider the goals of the total program when making decisions.
4-Step Disciplinary Procedure
In the event that an Upward Bound student should engage in or display behavior that is in clear violation of this document
or the summer RULES, RULES, RULES, RULES, RULES document of the UWSP Upward Bound Program, the
following four-step process will be immediately implemented within 24 hours of the violation:
STEP 1:
The student or students implicated in a rule violation will receive a written disciplinary report
from the reporting program staff member. The reporting staff member and student will then meet with the
Residence Hall Director or Coordinator/Academic Advisor to discuss the violation and log the infraction.
A file is kept.
STEP 2:
After a second offense or Rule Violation the consequences for the student will be the withdrawal of
privileges to include, but not limited to the suspension of off-campus privileges and scheduled recreational
activities. In addition, the student will be required to sign a written contract (Student Disciplinary
Contract), which specifies certain conditions that must be abided by in order to remain enrolled in the
Upward Bound Program. A copy of all materials will be sent home to the student's parent/guardian.
STEP 3:
After a third offense or Rule Violation, the Upward Bound Director will impose a three (3) day
suspension from the program for the student involved. The student's parents or guardian must remove
the student from the Upward Bound summer session for three consecutive weekdays and return the
student back to campus upon completion of the suspension. Upon return to the summer session, the student
must make-up all class work missed as well as abide by the terms of his/her written contract (Student
Disciplinary Contract).
STEP 4:
After a fourth offense or Rule Violation, the student will be dismissed from the Upward Bound
Program. No appeals or exceptions will be considered. The decision of the Upward Bound staff in
conjunction with the Program Director is final! Based on circumstances the student may become and active
participant once again in fall.
NOTE:
Depending on the nature/severity of the infraction or Rules Violation an Upward Bound participant may
receive a Step 1, 2, 3, or 4, immediately. Upon successful completion of the summer session any student
with step violation(s) will be returned to "good standing" within the program.
The faculty/staff of the UW-Stevens Point Upward Bound Program is committed to helping students modify
behavior that may be detrimental to their well-being and to the overall functioning of the Upward Bound
Program. Upward Bound has found this 4 Step Disciplinary Procedure, when consistently applied is an
approach that is fair and effective for every Upward Bound participant. Rule violations in conjunction with
appropriate disciplinary action rest solely with Program Director's authority, relative to staff recommendations.
What Does Upward Bound Provide To Its Participants?
Help with preparing and succeeding in college.
The opportunity to meet other students from across central/northern Wisconsin.
Academic instruction to prepare for college.
Parent/student workshops twice per school year.
Activities in educational, cultural and recreational areas.
Transportation provided to and from events.
Materials/supplies provided in all areas.
Opportunities to learn about other cultures.
The chance to find out what one's academic potential is.
Recreational and cultural field trips in and out-of-state.
Community Service opportunities.
Assistance in completing admissions applications.
Assistance in completing financial aids applications
Tutorial services.
Academic advisement.
Personal counseling.
Peer Mentor Program.
Career counseling/exploration.
College campus tours.
ACT/SAT preparation.
Fall/Spring overnight Workshops.
 Scholarship opportunities.
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