2014-2015 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
--UWSP Camp Health Form (2 pages) Consent for Medication Administration and
Medical Treatment AND Camp Health Form (is required for the student)
--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) A signed notarized statement indicating family income for the prior year.
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.
9/2014
The Upward Bound Program has been hosted by the University of Wisconsin-Stevens Point for 46
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 10 target high schools in the 7 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 session 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 session. During summer session, 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. Summer session is a very involved intensive 7 day a week experience.
Each September, Upward Bound staff evaluates each student's social and academic progress for the
prior summer session. 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 postsecondary entrance and success at the college of their choice.
9/2014

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 2015:
8th
9th
10th
11th
13.
SCHOOL YOU ARE NOW ATTENDING: ___________________________________________
(school name)
9/2014
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
SCHOOL INFORMATION FORMS
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 a signed notarized statement
indicating family income for the past year. 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
*Students who are both Low Income and
First Generation in status have the best
chance for admission to Upward Bound.
9/2014
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 program June 16–July 27, 2014 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.


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 2.50 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:
______ 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 applicant will have completed by this 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 WKCE Test Scores and
Return TO: Upward Bound Program, 204 Nelson, University of WisconsinStevens Point, Stevens Point, WI 54481-3897.
9/2014
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 summer session during the first year of enrollment.
2. Participating in additional summer sessions 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 Program activities.
6. Participating in at least two (school year) College Campus Visits.
7. Participating in Parent/Participant Workshops - 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 (2.50 OVERALL FOR JUNIORS AND SENIORS).
I WILL PARTICIPATE IN THE 2015 SUMMER SESSION (JUNE – JULY, 2015, AS REQUIRED).
I WILL PARTICIPATE IN THE 2014-2015ACADEMIC YEAR PROGRAM (September 1, 2014 through May 31, 2015).
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 (2.50 OVERALL FOR JUNIORS AND SENIORS).
I WILL PARTICIPATE IN THE 2015 SUMMER SESSION (JUNE-JULY, 2015, AS REQUIRED)
I WILL PARTICIPATE IN 2014-2015 ACADEMIC YEAR PROGRAM (September 1, 2014 through May 31, 2015).
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: _____________

UWSP Camp Health Form
Camp Name:
Dates:
Please fill out front page AND back page
Upward Bound Program
January 1, 2015, through April 30, 2016
Birth date ____/____ ____
Camper Name:
Custodial Parent/Guardian (or spouse)
Phone
Home (
) _______-_________
Numbers:
Age on 1st day of camp
Sex: Male / Female
E-mail address:
Work (
) _______-___________
Cell phone (
) ______-__________
Home address
Street
Second parent/guardian
and/or emergency contact:
City
State
You must list Second contact on line below 
Phone: Home (
Work (
Zip
) ______-__________
) _______-__________
Address
Street
City
State
Zip
CONSENT FOR MEDICATION ADMINISTRATION AND MEDICAL TREATMENT
TO THE PARENT(S) OR LEGAL GUARDIAN:
If your son, daughter, or ward will be under the age of 18 while at the University of Wisconsin – Stevens Point, it is camp policy to
secure your consent for medication distribution and for the use of medical devices. The medication or medical device can be
self-administered or be administered by designated camp health staff with the exception that controlled drugs (i.e., Codeine,
Ritalin, Adderall, Dexedrine, etc.) must, by law, be administered by camp health staff.
All prescription medication must be in the original medicine bottle (see picture at right) and labeled with the camper’s name,
doctor’s name, medication name, dosage, prescription number, date prescribed, and instructions. You must complete the form
below:
 No medication(s) has been brought to camp.
 I want the medication or medical devices self-administered (age 14 and above only).
 I want the medication or medical device administered by the designated camp staff. However, a
limited amount of medication for life-threatening conditions may be carried by my
son/daughter/ward (i.e., bee sting kit, inhaler, insulin syringe).
If your son, daughter, or ward will be under the age of 18 years while at camp, it is our policy to secure your consent for all of the following. By
signing below,
I am giving my consent in advance for medical treatment at an appropriate medical facility in case of illness or injury.
I am stating that I am aware of and accept the risk inherent in the program activity.
I attest that all information on both sides of this form is correct.
I agree to hold harmless and indemnify the Board of Regents of the University of Wisconsin System, and the University of Wisconsin –
Stevens Point, their officers, agents, and employees from any and all liability, loss, damages, costs, or expenses which are sustained,
incurred or required arising out of the actions of my son, daughter or ward in the course of the camp/event.
Participant Name (Please Print)
SIGNATURE OF PARENT OR LEGAL GUARDIAN
Back Page MUST be filled out
Date
Page 2
UWSP Camp Health Form (Continued)
Health Conditions (check)






Allergies (check & list specifics)
 Insect stings
 Foods
 Medications
 Other
Asthma
Diabetes
Epilepsy
Any dizziness, light-headedness or fainting associated
with exercise within the past year
Any unexplained, rapid or irregular heart beat within
the past year
A physician has sometime denied or restricted
participation in sports due to a heart problem
____________________________________________
____________________________________________
____________________________________________
____________________________________________
Do any allergies require an EPIPEN Injection?
 Yes
 No
Date of last Tetanus booster: ________________________________
Name of Insurance Company: ____________________________________
Policy #: _____________________________
Description of any limitation or restriction of camp activities:
Any other special physical or emotional conditions that we need to be aware of regarding your child’s participation in this camp (include
circumstances when physician should be notified)? _______________________________________________________________________________
Medications camper will be taking at camp:
Name of Medication
Reason
Dosage (mg)
Times of day given
Prescribing Physician & Phone
Number
 Yes
1.
Does the camper experience any side effects from the medication? (i.e., mood/behavior changes, upset stomach, diarrhea)
2.
List any special instructions or additional information regarding the medication that would be helpful to the Health Care staff:
 No
___________
*** FOR CAMP USE ONLY – TO BE COMPLETED BY HEALTH CARE STAFF AT CHECK-IN ***
 No
 Yes
1.
Are there any changes in your child’s health status since the medical forms were sent in?
2.
Has your child, or anyone in your family been sick or exposed to any communicable disease in the past month?  No
3.
Does your child now have any rashes or open sores?
4.
Are there any changes in your dependent’s medications? (If Yes, Staff make changes on other side & sign)
5.
Does your child have any recent injury or activity restrictions?
6.
Will the custodial parent(s) or guardian be available at the numbers listed on this form during the camping session?  No
 Yes
If NO, list the name & phone number of person(s) authorized to make decisions on their behalf:_____________________________________________
 No
 Yes
 Yes
 No
 No
 Yes
 Yes
_________________________________________________________________________________________________________________________
Information provided by:
To:
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 similar programs. 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 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
09/2014
Federal TRIO Programs
2014-2015 Low-Income Levels
(Effective January 28, 2014, until further notice)
To Determine Low-Income Eligibility
Size of Family Unit
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2
3
4
5
6
7
8
Annual Family Income
48 Contiguous States
D.C., and Outlying
Jurisdictions
$17,505
$23,595
$29,685
$35,775
$41,865
$47,955
$54,045
$60,135
Alaska
$21,870
$29,490
$37,110
$44,730
$52,350
$59,970
$67,590
$75,210
Hawaii
$20,130
$27,135
$34,140
$41,145
$48,150
$55,155
$62,160
$69,165
For family units with more than eight members, add the following amount for each additional
family member: $6,090 for the 48 contiguous states, the District of Columbia and outlying
jurisdictions; $7,620 for Alaska; and $7,005 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 Annual 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,
http://www.gpo.gov/fdsys/browse/collection.action?collectionCode=FR&browsePath=2014%2F1&isCollapsed=true&leafLevelBrowse=false&ycord=126; and
are effective until further notice.
Attention Applicant: This form is for your records, DO NOT return to Upward Bound.
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.
9/2014
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:
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2.
3.
4.
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
5. Display Academic Honesty in Completing Their Work
6. 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 session
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, send 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.
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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.
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2. All new students who are currently in the 9 , 10 or 11 grades are expected to complete the entire
summer session. 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 session, 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
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session (emergencies excluded). Of the 2 weekends spent at home, the 4 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
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beginning of the summer session, during the 4 of July break and their return home at the completion of
the session. 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 at Camping Trip departure they
will be required to participate. All other transportation is the responsibility of the parent or other authorized
adult.
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 Summer
Session Programing 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 Session or Summer
Sessions be 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, loss of phone 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 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 session students need to drink water as often as possible to combat dehydration and
“heat stroke.”
Credit Recommendations

At the completion of the summer program a recommendation for credit is sent to both the student's
parent/guardian and home high school during September. A recommendation for FULL CREDIT, ONEHALF 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., pick-up, postage, etc.). Students are expected to be responsible for their personal
belongings.
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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