Upward Bound Programs
Student Application
Phone: 330-672-2920 Fax: 330-672-5339
*
PLEASE PRINT CLEARLY or TYPE
Today’s Date______________ Applicant Gender (circle one): Male Female
Current Age: _____________
Indicate the Parent with whom the student resides during the academic year: __ Mother __ Father __ Both __ Guardian
Student Name ___________________________________________________________________________________
First
Middle
Last
Current Address_________________________________________________________________________________
Street
City
State
Zip
Home Phone Number: _______________________________
Parent Email Address: _________________________________
Parent Cell Phone Number: ___________________________
Emergency Phone Number: _____________________________
Student Cell Phone Number: __________________________
Student Email Address: ________________________________
Ethnicity:
[
] Hispanic
[
] Non-Hispanic
Race:
[
[
[
] Black or African-American
] Native American or Other Pacific Islander
] American Indian or Alaskan Native
[
[
] White
] Asian
MARK ALL THAT APPLY
Student SS#_________________________________
Date of Birth __________ _________ ___________
Month
Day
Year
Are you: [ ] a U.S. Citizen [ ] an eligible non citizen (please provide copy of immigration document)
[ ] other ____________________________
Primary Language Spoken at Home: __________________________________________________________
Name of Current School: ______________________________________
Circle Current Grade Level
9 10 11
Guidance Counselor: ___________________________________
Does Student Currently Have an IEP on file:Yes____________ No_____________ (If yes, please attach copy of IEP)
List all persons living in your home, including yourself. (USE ADDITIONAL SHEET IF NECESSARY)
NAME
AGE
RELATIONSHIP
OCCUPATION OR NAME OF SCHOOL
PLEASE ANSWER THE FOLLOWING QUESTIONS.
1.
EXPLAIN YOUR ANSWERS CAREFULLY AND AS COMPLETELY AS POSSIBLE.
Are you available for the after school College Club tutoring sessions? _________________________________________________
If not, please explain___________________________________________________________________________________________
2.
Are you interested in attending the summer institute?
_____________________________________________________________________________________________________________
3.
What jobs or careers are of interest to you?
_____________________________________________________________________________________________________________
4.
How would you describe your past academic performance? __________________________________________________________
5.
What do you plan to do after you graduate from High School? (Check all that apply)
___ Attend a four-year college
___ Attend a Community College (2 year degree)
___ Enroll in a technical college program
___ Enlist in the military
___ Get a job
___ Attend a trade school
___ Other (please explain) ________________________________________________
PLEASE ANSWER THE FOLLOWING SHORT ANSWER QUESTIONS. PLEASE PRINT AND ANSWER THOROUGHLY.
(ATTACHED ADDITIONAL SHEET IF NECESSARY)
1.
Please tell us why you would like to participate in the Upward Bound Program?
2.
If you were given the opportunity to create/invent something or own your own business; what would it be? Please explain why.
Student Name:
Upward Bound Programs
Eligibility Determination
THIS PAGE IS FOR PARENTS/GUARDIANS TO COMPLETE
Father/Male Guardian Name:
Mother/Female Guardian Name:
______________________________________________
Last
First
MI
____________________________________________________
Last
First
MI
Highest educational level completed (Please Check)
___ High School (9-12 grade)
___ Associates Degree (2 years)
___Bachelors Degree or beyond (4+ years)
___ Other _________________________(Please list)
Highest educational level completed (Please Check)
___High School (9-12 grade)
___ Associates Degree (2 years)
___ Bachelors Degree or beyond (4+ years)
___ Other __________________________(Please list)
**FOR PARENTS OR LEGAL GUARDIANS ONLY**
INCOME INFORMATION
(THIS INFORMATION WILL BE KEPT STRICTLY CONFIDENTIAL AS REQUESTED PER FEDERAL GUIDELINES)
Please attach a copy of your most recent Federal Income Tax Return
PLEASE CALL IF YOU HAVE ANY QUESTIONS REGARDING THIS SECTION 330-672-2920 OR 1-888-215-9637
Line 43 of the 1040 form, or line 6 of the 1040 EZ form, or line 27of the 1040A is (Taxable Income) $____________________________
Total number in Household ________
Families receiving ADC or other public benefits:
ADC Case Number
Other: ________________
____________________
_____________________
Foster Child: If student is a foster child, please check here.
List income and how often received: $____________________ per __________________ (month, week, or year).
Families not receiving public assistance: IT IS VERY IMPORTANT THAT A COPY OF PARENTS OR GUARDIANS LAST INCOME TAX
STATEMENT be attached. Your application will not be considered until the tax forms are received along with your completed application.
SIGNATURE: An adult household member must sign this statement and complete the requested information BEFORE the application can be
approved.
I certify that all of the above information is true and correct and that the ADC number is correct and that all income is reported. I
understand that this information is being provided for the receipt of federal funds.
I pledge my support and commitment to Upward Bound and to my student’s academic success.
Parent/Guardian’s Signature______________________________________Date_________________
Parent/Guardian’s Signature______________________________________Date_________________
Student Name:
This form can be returned by:

Fax

Mail

Returned to student in a sealed envelope
Upward Bound Programs
Guidance Counselor Evaluation Form
Phone: 330-672-2920 Fax: 330-672-5339
The student whose name appears above is applying for admission to the Kent State University Upward Bound Program. Your candid
opinion of this student’s academic performance, intellectual promise and qualities as a person will be of significant value to our
application review committee. Please complete and return to the Upward Bound counselor coordinating applications this year.
Please Attach a Copy of the Following:
 Complete Academic Transcripts
 Most Recent Grade Card
 Copy of Attendance Records (current & previous year)
 Copy of Test History / Summary
 Copy of IEP’s or Special Needs Plan (if applicable)
CURRENT GRADE POINT AVERAGE / ATTENDANCE RECORD:
How long have you known the applicant__________ Applicant’s Current Grade_____________
Applicant’s Cumulative Grade Point Average___________ Class Rank_____________________
Grade Point Average during the last Marking Period__________
Has this applicant ever been suspended from your school? Yes__________ No_____________
Is Yes; Please Explain______________________________________________________________________________________
________________________________________________________________________________________________________
Ohio Achievement Assessments:
Middle School:
Did student meet state academic achievement standard for English Lang. Arts ____Yes ____No
Did student meet state academic achievement standard for Mathematics _____Yes _____No
High School:
Ohio Graduation Test_________ Scores__________ __________ __________ _________ _____________
Date
Math
Writing
Science
Reading Social Studies
College Entrance Exam Record:
EXPLORE_________ _________ PLAN__________ _________ ACT_________ _____________
Date
Composite
Date
Composite
Date
Composite
SAT________ _________ PSAT_________ ___________ Other Assessments________________
Date
Score
Date
Score
CAREER / VOCATIONAL TRACK:
Pre-College______________ Vocation_______________ Other__________________________
What are the first three words that come to mind in describing this student?
1.________________________ 2._________________________ 3.________________________
ACADEMIC RATING: Please check the appropriate box.
Below
Average
Average
Good
Excellent
Cannot Assess
Natural Ability
Achievement in relation to ability
Study Habits
Motivation
Quality of Written English
On the basis of academic promise, how
would you recommend this applicant to
KSU Upward Bound?
____
____
____
____
Highly Recommend
Recommend
Recommend with Reservations
Do Not Recommend
CHARACTER & PERSONAL RATING: Please check the appropriate box.
Below
Average
Average
Good
Excellent
Cannot Assess
Emotional Maturity
Self-Confidence
Interpersonal Skills w/ Peers
Interpersonal Skills w/ Adults
Cooperation with Others
Respect for Teachers /Staff
Leadership Potential
Independence
Self-Initiative / Motivation
Ability to Cope w/ Failure
Creativity
Overall Responsibility
Ability to Set/Achieve Goals
Study Habits
Potential for Success in College
On the basis of character & personal
promise, how would you recommend this
applicant to KSU Upward Bound?
____
____
____
____
Highly Recommend
Recommend
Recommend with Reservations
Do Not Recommend
_____________________________ ____________________________
Counselor Name
Signature
_________________
Date
This form can be returned by:

Fax

Mail

Returned to student in a sealed envelope
Upward Bound Programs
ENGLISH Teacher Evaluation Form
Phone: 330-672-2920 Fax 330-672-5339
Name of Student______________________________
Name of Course_____________________________________
Is this course designed as a remedial or special education course? Yes_________ No__________
Have you taught this student in classes other than the one above? Yes______ No______
If yes, what courses: _____________________
Please place check marks at the points that represent your evaluation of the student in comparison to other students in his or her age group whom
you have taught. If you have no fair basis for judgment, do not hesitate to say so.
One of the top
students I’ve ever
encountered
Excellent (top
10% this year)
Good / Above
Average
Average
Below
Average
No Basis for
Judgment
Academic Potential
Intellectual Curiosity
Effort / Determination
Ability to Work Independently
Organization
Creativity
Willingness to take Intellectual Risks
Concern for Others
Honesty / Integrity
Self-Esteem
Maturity (relative to age)
Responsibility
Respect Accorded by
Faculty/Teachers
Respected Accorded by Peers
Emotional Stability
Overall Evaluation as a Person
Overall Evaluation as a Student
Briefly describe this student’s reading and writing ability. How accurately does the student read and understand what he or she has read? How well
does the student write in comparison with other students on the same grade level?
If the student is relatively weak or strong in any areas listed above, please elaborate:
What are the first three words that come to mind in describing this student?
1.________________________ 2._________________________ 3.________________________
Thank you for taking your valuable time to complete this evaluation. Your reflections are an important part of the student’s application.
_______________________________________
Signature
______________________________
Date
_________________________________
Email Address
__________________________________________
Telephone
Please return this form to the guidance department at your school to be included in the student’s application packet.
Upward Bound Programs
MATH Teacher Evaluation Form
Phone: 330-672-2920 Fax: 330-672-5339
Name of Student______________________________
This form can be returned by:

Fax

Mail

Returned to student in a sealed envelope
Name of Course_______________________
Is this course designed as a remedial or special education course? Yes_________ No__________
Have you taught this student in classes other than the one above? Yes______ No______ If yes, what courses: ________________
Please place check marks at the points that represent your evaluation of the student in comparison to other students at their grade level:
One of the top
students I’ve ever
encountered
Excellent (top 10%
this year)
Good / Above
Average
Average
Below
Average
No Basis for
Judgment
Knowledge of the Basic Skills
Accuracy in the Use of Basic Skills
Problem Solving Ability
Reasoning Ability
Understanding of and Appreciation for the
Underlying Ideas and Concepts
Overall Performance
Willingness to Accept the Challenge of the more
difficult problems or exercises
Command of mathematics when compared to
other students in the class or at the same grade
level
Please place check marks at the points that represent your evaluation of the student in comparison to other students at their grade level:
One of the top
students I’ve ever
encountered
Excellent (top 10%
this year)
Good / Above
Average
Average
Below
Average
No Basis for
Judgment
Academic Potential
Intellectual Curiosity
Effort / Determination
Ability to Work Independently
Organization
Creativity
Willingness to take Intellectual Risks
Concern for Others
Honesty / Integrity
Self-Esteem
Maturity (relative to age)
Responsibility
Respect Accorded by Faculty/Teachers
Respected Accorded by Peers
Emotional Stability
Overall Evaluation as a Person
Overall Evaluation as a Student
If the student is relatively weak or strong in any areas listed above, please elaborate:
What are the first three words that come to mind in describing this student?
1._________________________ 2.__________________________ 3._______________________
Thank you for taking your valuable time to complete this evaluation. Your reflections are an important part of the student’s application.
_______________________________________
Signature
______________________________
Date
_________________________________
Email Address
__________________________________________
Telephone
Please return this form to the guidance department at your school to be included in the student’s application packet.