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					Dear Student and Parent(s)/Guardian(s):

Thank you for considering the Missouri State University TRIO Upward Bound Program. Upward
Bound offers students a chance to experience college life while still attending high school. The
program provides many exciting educational opportunities and cultural activities to broaden students’
perception of themselves and the world around them.

The Upward Bound staff assists students by providing: 1) academic support and tutoring, 2) career
guidance, 3) social and cultural development, and 4) counseling and survival skills. The program is
designed to develop the skills and confidence necessary to succeed in postsecondary.

The Upward Bound program pays for all expenses, including trips and lunches, when the student is
involved in Upward Bound activities. After reviewing the description of the program, you may decide
that the Upward Bound Program is for you/your student. If so, fill out the enclosed application and
return it to your high school site coordinator (Ms. Simmons – Central; Ms. Schirk– Hillcrest; Ms. Lord
– Parkview) or to the TRIO Upward Bound Office at Missouri State University. Upon receipt of
your application, the Upward Bound staff will determine your eligibility for the program and if
eligible, contact you/your student for an interview with both students and parents/guardians.

If you have any additional questions concerning the Upward Bound Program and what it can do for
you/your student, please contact me by phone at 836-3117 or at obrien10@missouristate.edu.
Once again, thank you for your interest in the Upward Bound Program and best of luck with your
application.

Sincerely,



Kate O’Brien
Program Coordinator, TRiO Upward Bound
                                  About the Upward Bound Program….

     The Missouri State University TRIO Upward Bound Program is a pre-college program administered
     by the U.S. Department of Education and is designed to motivate and prepare high school students
     for postsecondary education. The program serves 50 students in 9th through 12th grades at Central,
     Hillcrest, and Parkview high schools. Students who are accepted into the program remain in the
     program until graduation from high school or until the student is released from the program, either
     voluntary or involuntary.

     Priority is given to applicants whose economic status or taxable income meets the Federal TRIO
     Income Guidelines (see second page of Part III: Parent/Guardian Information) and who demonstrate
     academic need. Although grades are important, they are not necessarily used in determining whether
     or not a student is eligible for Upward Bound; throughout the program, students must demonstrate
     academic potential.

     The following is a brief outline of the services that a student will receive through Upward Bound:

               Academic Year Component (September-May):
                Tutoring sessions twice per month at your high school, more if your GPA requires it
                Meeting with site coordinator once per month at your high school
                Meetings with UB staff once per week at your high school
                Various activities in Springfield and at Missouri State University
                Saturday Destined for College Meeting once per month at Missouri State University
                     o Includes career, college, cultural and academic activities

               Summer Component (June-July):
                High school-level instruction (Monday-Thursday for six weeks) at Missouri State
                    o Includes instruction in Math, Science, Foreign Language, English, Social Sciences,
                         and Electives
                    o Lunch
                    o Evening activities
                    o Fun Fridays-includes trips, college tours, sports, and other recreational activities
                Possible out-of-state Cultural/Educational Trip

               Year-Round Services
                Personal, academic and career counseling/advising
                Stipends-monetary rewards given to students for participation
                     o Up to $40 per month during the academic component
                     o Up to $60 per month during the summer component
                ACT/SAT Preparation
                College Tours
                Field Trips
                Financial Aid and Scholarship Education

       All expenses for participating in the Upward Bound programs, activities and events are paid for by the Program.




The Missouri State University TRIO Upward Bound Program is funded by the U.S. Department of Education and Missouri State University.
  Missouri State University™
  TRIO Upward Bound
  Application for Admission


                                                      Part I: Student Information

  Name
                     (Last)                                  (First)                                (Middle)

  Address
                     Street Address or PO Box                          City               State                Zip Code

  Contact Information
                                         Home Phone                    Alternate Phone                         Email Address

  High School                                                                             Grade

  Date of Birth                                                                 Place of Birth

  Social Security #                                                    Gender             Male                 Female

  (If you do not have a Social Security number, please check here.                        )

  Marital Status (check one)                       Single (never married)                            Married
                                                   Divorced                                          Widowed

  Ethnicity                               African American                                                     Hispanic/Latino
  (This information is                    Native American/Native Alaskan                                       Asian
  optional and will be                    Native Hawaiian/Pacific Islander                                     Caucasian
  used for reporting                      Multiracial (please specify)
  purposes only.)                         Other not listed (please specify)

  US Citizen?                             Yes                No
  Resident Alien?                         Yes                No        Alien Registration # A

  Have you ever applied to an Upward Bound Program before?                                 Yes                 No
  Have you ever been a member of an Upward Bound Program?                                  Yes                 No

I attest to the fact that the above information is true and accurate to the best of my knowledge.

I understand the purpose of the Missouri State University TRIO Upward Bound Program, which is to prepare
participants to successfully complete a program of postsecondary education. As part of my personal effort in
this preparation, I commit to Upward Bound and intend to participate in all academic year and summer
components of the program. I understand that attendance is an integral part of participating. Therefore, I agree
to attend and actively participate in all classes, meetings and activities sponsored by Upward Bound. I will
comply with all rules and regulations of the TRIO Upward Bound Program, and I am aware that failure to comply
could result in dismissal from the program.

I understand and willingly commit to meeting these expectations.

APPLICANT’S SIGNATURE                                                                  DATE




      The Missouri State University TRIO Upward Bound Program is funded by the U.S. Department of Education and Missouri State University.
                                             Part I: Student Information Continued

 A. Exam Information

 A.1. Have you taken the PSAT? Ο Yes Ο No                            If yes, please state date taken:_____ / score: _____
 A.2. Have you taken the SAT? Ο Yes Ο No                             If yes, please state date taken:_____ / score: _____
 A.3. Have you taken the ACT? Ο Yes Ο No                             If yes, please state date taken:_____ / score: _____
 A.4.Have you taken the ACT Plan? Ο Yes Ο No                         If yes, please state date taken:_____ / score: _____

 B. Student Goals

 B.1. What is your career interest?
 B.2. Do you plan to attend college? Ο Yes Ο No
 B.3. Do you want to attend college? Ο Yes Ο No
         a. If yes, which college(s) are you interested in attending?

 C. Student Interests

 C.1. What are your hobbies and/or interests?
 C.2. What school activities, clubs or other extracurricular activities in which you participate?


 C.3. What is your favorite subject?                                                    Least favorite?
 C.4. What is the title of the last book you read that was not assigned to you by a teacher?


 C.5. Why do you want to join the Missouri State University Upward Bound Program? (Check all that apply.)

          Academic support/enrichment                                Tutoring services
          Personal support/counseling                                Encouraged to apply by family
          Career counseling                                          Field trips
          Assistance with college admission                          Destined for College Meetings
          Assistance with financial aid                              Assistance with the ACT/SAT
          To make friends                                            Other

                                               Part II: PERSONAL STATEMENT

Directions: On a separate sheet(s) of paper, please address ALL of the following items in ESSAY FORM in at
least 100 words. Please type or print NEATLY.
    st
   1 Paragraph:                     Introduce yourself and include information about your family and school.
    nd
   2 Paragraph:                     Write about your background: where and how you were raised; any interesting
                                    incidences in your life.
    rd
   3 Paragraph:                     Write about your plans for the future, including your college, career, and personal
                                    plans and goals.
    th
   4 Paragraph:                     Discuss two of your academic strengths and academic weaknesses and two of your
                                    personal strengths and personal weaknesses.
    th
   5 Paragraph:                     Explain why you want to become a part of the TRIO Upward Bound Program AND
                                    describe what role you see the Upward Bound program playing in your life and
                                    college/career plans.



    The Missouri State University TRIO Upward Bound Program is funded by the U.S. Department of Education and Missouri State University.
                                                                    Part III: Parent/Guardian Information

   Student lives with:                                     Mother & Father                                        Foster Parent(s)
                                                           Mother only                                            Guardian(s)
                                                           Father only
                                                           Relatives or other (specify)

                                  FIRST GENERATION ELIGIBILITY VERIFICATION –All information is kept confidential!

Father/Guardian                                                                                  Mother/Guardian
Name:                                                                                            Name:
Occupation:                                                                                      Occupation:
Work Phone:                                                                                      Work Phone:
Cellular Phone:                                                                                  Cellular Phone:

Highest Education Level Attained: (please check one)                                             Highest Education Level Attained: (please check one)
                                                                                                            th
         Elementary (K-8) High School (9-12)                                                              12 Grade or Lower
         Some College               Associate Degree                                                      Some College               Associate Degree
         BA/BS Degree (Country where degree was                                                           BA/BS Degree (Country where degree was
        obtained                                     )                                                   obtained                                     )
         Graduate Degree (Country where degree was                                                        Graduate Degree (Country where degree was
        obtained                                     )                                                   Obtained                                     )
         Unknown                                                                                          Unknown


                                            INCOME ELIGIBILITY VERIFICATION –All information is kept confidential!

Did you complete an Income Tax Return last year?                         Yes                No
        If you answered yes, please submit a copy of last year’s signed tax return, which includes your 1040. Skip the rest of
         this box and sign below.
        If you answered no, please enter your information below.

     HOUSEHOLD MEMBERS                        Gross MONTHLY Earnings                     MONTHLY Welfare                         MONTHLY Payments                       Any other
     List the names of everyone                  (Before Deductions)                   Payments, Child Support,                    from Pensions,                     Monthly income
       currently residing in the                                                           Alimony, Public                        Retirement, Social
              household                                                                       Assistance                          Security, Veteran
                                                                                                                                       Benefits
                                                 Job 1                Job 2
   1.
   2.
   3.
   4.
   5.
   6.
   7.
   8.
(Note, this information is necessary for determining program eligibility and is required of all families whose child/children are served by the Upward Bound Program. Your cooperation is
needed in filling out the information completely and attaching a copy of your last year’s US Income Tax Return.)

I certify that all of the above income information is true and correct and that all income is reported. I understand that any misrepresentation
may make my student ineligible for participation.

PARENT/GUARDIAN SIGNATURE                                                                                                               Date


I understand the purpose of the TRIO Upward Bound Program, which is to prepare participants to successfully complete a program of
postsecondary education, and would like to have my child participate. Because parent involvement and support are major contributing factors
to student success, I agree to be involved in the following ways: 1) keeping informed of my child’s progress in school; 2) encouraging my child
to attend all information is necessary for determining program participating in is required of all families invited; 5) sharing
Note: This UB activities; 3) allowing my child to attend UB field trips; 4) eligibility andUB events in which parents arewhose children
concerns about my child’s education with Program. Your cooperation is needed in filling out the behalf of my child. I support the
are served by the Upward Bound Upward Bound staff; 6) supporting the UB staff in their efforts on information completely
mission of Upward Bound and will make it a priority to assist my child in his/her education. In addition, I authorize my student to be transported
to and from Upward Bound activities by an US Income staff Return.
and attaching a copy of last year’s Upward Bound Tax member in a University vehicle or in the staff member’s personal vehicle.

  certify that all all the above income information is true and correct and that all or misrepresentation will understand
I hereby attest thatof the information is true and correct. I also understand that a false statementincome is reported. Imake the applicant
ineligible for the Missouri is being given for the receipt ofProgram. funds and any misrepresentation on my part may make
that this information State University TRIO Upward Bound federal
the applicant ineligible for participation.
PARENT/GUARDIAN SIGNATURE                                                                                                               Date

PARENT/GUARDIAN SIGNATURE                                                                                                                             Date
         The Missouri State University TRIO Upward Bound Program is funded by the U.S. Department of Education and Missouri State University.
Federal TRIO Programs
2010 Annual Low Income Levels

2010 TRIO Low-Income Levels: On January 22, 2010, the U.S. Department of Health and Human
Services (HHS) published a Federal Register notice advising that the 2009 poverty guidelines will
remain in effect until updated 2010 poverty guidelines are published which will not be before March
1. Since the Department uses the HHS poverty guidelines to update the TRIO low-income levels,
TRIO grantees shall use the TRIO 2009 Low Income Levels, below, until further notice.

(Effective January 23, 2009 Until Further Notice)


  Size of Family Unit                      48 Contiguous States,                                 Alaska                   Hawaii
                                      D.C., and Outlying Jurisdictions

               1                                        $16,245                                 $20,295                  $18,690

               2                                        $21,855                                 $27,315                  $25,140

               3                                        $27,465                                 $34,335                  $31,590

               4                                        $33,075                                 $41,355                  $38,040

               5                                        $38,685                                 $48,375                  $44,490

               6                                        $44,295                                 $55,395                  $50,940

               7                                        $49,905                                 $62,415                  $57,390

               8                                        $55,515                                 $69,435                  $63,840


For family units with more than eight members, add the following amount for each additional family
member: $5,220 for the 48 contiguous states, the District of Columbia and outlying jurisdictions;
$6,525 for Alaska; and $6,000 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, Vol. 74, No. 14, January 23, 2009, pp. 4, 199-4, 201.




   The Missouri State University TRIO Upward Bound Program is funded by the U.S. Department of Education and Missouri State University.
Part IV: HEALTH STATEMENT

A. Please list any and all medical problems, disabilities, or physical conditions that your child may have which might
affect or be affected by participation in this program and which the TRIO Upward Bound Staff should know about.




A.1. If a medical problem exists, what assistance would you need from the Upward Bound staff?



B. Medications taken regularly:


C. Allergies (including allergies to medications):


D. Limitations on physical activities:


E. Name of medical insurance and policy number                                                             #

F. Wears contacts?                    Yes                 No        G. Wears glasses?                       Yes                 No



   Name of Physician                                                             Office Phone Number

   Emergency Contact #1: Name                                                              Relation
                         Phone Number

   Emergency Contact #2: Name                                                              Relation
                         Phone Number



                                                    MEDICAL RELEASE
                                                          For


                   First Name                             Middle                                  Last Name

 In case of emergency, I do          do not         hereby grant permission to the Project Director of the
 Missouri State University TRIO Upward Bound Program, or the Director’s authorized representative, to
 furnish first aid as my child (named above) may require, as well as to seek medical attention through the
 nearest medical facilities such as those provided on campus and those medical facilities available when
 students are on field trips and other authorized activities.

 This permission is conditioned upon the understanding that, in the event of serious illness or the need for
 hospitalization and/or major surgery, the Director or authorized representative will use all reasonable
 efforts to contact me. However, failure in such efforts should not prevent the Director from providing such
 emergency treatment as may be necessary for the best interest of the life of my child.

 I will not, in any way, hold Missouri State University or the TRIO Upward Bound Program responsible for
 any treatment deemed necessary, medical or otherwise.

 PARENT/GUARDIAN SIGNATURE                                                                         DATE




   The Missouri State University TRIO Upward Bound Program is funded by the U.S. Department of Education and Missouri State University.
                                          PART V: INFORMATION RELEASE FORM

STUDENTS AND PARENTS/GUARDIANS: Please complete the top portion of this form.

Student’s Name                                                                         High School

SSN                                                       Current Grade:               9                    10                  11

I hereby give the Missouri State University TRIO Upward Bound Program permission to receive copies of
educational records and other materials necessary for participation in the Program. Further, permission is granted
to request academic and financial aid information and records from any and all postsecondary institution is order to
track college progress. I understand all of my records will be kept in confidence and in accordance with the Privacy
Act of 1974.

You have our consent to release grades, test scores, and any other academic records to the Missouri State
University TRIO Upward Bound Program.


        (Student’s Signature)                                       (Parent’s Signature)                                   (Date)


                                PART VI: GUIDANCE COUNSELOR RECOMMENDATION

This student has applied to participate in the Missouri State University TRIO Upward Bound Program. The
information requested will help us in determining the student’s eligibility to participate. Please complete this portion
of the form adding appropriate comments as needed.

Student’s Cumulative GPA                                                     Student’s Class Rank

Attendance Record                      Excellent                    Good                          Fair                          Poor

Student’s motivation for enrolling in postsecondary education                           High                Middle              Low

Please select the subject areas in which you feel this student has an academic need (please include courses in
which the student needs credit or subjects in which the student would benefit from enhancement):
        Writing                                   Reading                                Math
        Science                                   Foreign Language                       History
        Career Information                        Self-concept                           Educational planning
        Other (please specify)

Does this student have limited English proficiency?            Yes                                No
Was/Is this student enrolled in any Advanced Placement course(s)?                                 Yes                 No
        If yes, which one(s)?

Please give your perception of this student’s academic potential. Include academic, social and family factors:



                            Important! Please return a copy of the following with this form:
                                    1. Student’s official high school transcript
                                    2. Student’s most recent report card
                                                                 th
                                    3. A printout of student’s 7 grade state test scores
                                    4. A copy of student’s middle school academic record

 Please sign below and attach this form to the other required forms. Insert all forms in an envelope. Please seal and sign the
     edge of the flap of the envelope and return to the student or fax the information to Upward Bound at (417) 836-6106.

Name of person completing this form                                                              Title

Signature                                                                                        Date


   The Missouri State University TRIO Upward Bound Program is funded by the U.S. Department of Education and Missouri State University.
                                  PART VII: FACULTY RECOMMENDATION
         To be completed by a teacher who has had this student enrolled in their class within the past year.

Student’s Name                                                                           High School
Current Grade                          9                  10                  11
Your Name                                                                                Title
Your Phone Number                                                     Your E-mail
Length of time you have known student

                                                                    Excellent                                            Poor
Has good class attendance                                             1              2            3            4           5
Demonstrates punctuality with assignments                               1            2            3            4            5
Seems motivated to achieve in class                                     1            2            3            4            5
Demonstrates good study habits                                          1            2            3            4            5
Accepts responsibility for his/her work                                 1            2            3            4            5
Demonstrates a good work ethic                                          1            2            3            4            5
Demonstrates good communication skills                                  1            2            3            4            5
Cooperates with peers                                                   1            2            3            4            5
Appearance/behavior reflect a positive self-image                       1            2            3            4            5
Exhibits dependable and reliable behavior                               1            2            3            4            5
Respects authority                                                      1            2            3            4            5
Student’s potential for postsecondary success                           1            2            3            4            5

From which components of the program do you feel the student would benefit the most?

        ____Destined for College Meetings                                                Personal counseling/support
        ____Career advising/exploration                                                  College student mentor
        ____Adult professional mentor/job shadowing                                      ACT preparation
        ____Field trips (college campuses, cultural events, etc.)                        Tutoring

Comments:



Would you recommend this student for the Missouri State University TRIO Upward Bound Program?

         Highly recommend                       Recommend with reservation                        Not recommend

Comments:


                                    Please sign below and Insert into an envelope.
                Please seal and sign the edge of the flap of the envelope and return to the student,
          or send to Missouri State University TRIO Upward Bound, 901 S. National Ave., Springfield, MO 65897,
                            or fax the information to Upward Bound at (417) 836-6106.


FACULTY SIGNATURE                                                                                          DATE




   The Missouri State University TRIO Upward Bound Program is funded by the U.S. Department of Education and Missouri State University.
                          Incomplete applications will not be accepted!!!
Before handing in this application, be sure that everything below is completed and included with
                                     your application packet.

                                                   Application Checklist:
    A. Page 3:
     Are all appropriate boxes and blanks filled in completely (if a question does not apply to you, please write
       “none”)?
     Did both you and your parents/guardians sign the appropriate fields?

    B. Page 4:
     Are all appropriate boxes and blanks filled in completely (no blanks!)?
     Did you include your personal statement in the exact format requested?

    C. Page 5:
     Are all appropriate boxes and blanks filled in completely?
     If your parents filed an income tax return last year, did you include a copy?
     If your parents did not file an income tax return last year, did you fill out your income information in the
        appropriate box?
     Did your parents/guardians sign the application in both places?

    D. Page 7:
     Are all appropriate boxes and blanks filled in completely (if a question does not apply to you, please write
        “none”)?
     Did your parents/guardians sign the appropriate field?

    E. Page 8:
     Are all appropriate boxes and blanks filled in completely?
     Did you include your guidance counselor’s letter of recommendation form and other documents in a sealed
        envelope?

    F. Page 9:
     Did you include your faculty (teacher’s) letter of recommendation form in a sealed envelope?

    Finally:
     Did you make a copy of this application for your records?

If the answer is “yes” to all of these, you are ready to submit your application! You may turn it in to your
high school’s site coordinator (Central – Ms. Simmons; Hillcrest – Ms. Schirk; Parkview – Ms. Lord) OR
send it directly to the Missouri State University TRIO Upward Bound Office at 901 S. National Ave.,
Springfield, MO 65897, or fax it to our office at 836-6106.

After submitting the application, we will process it and then contact you to schedule an interview with you and your
parents/guardians. If you have questions in the meantime, please contact our office.




   The Missouri State University TRIO Upward Bound Program is funded by the U.S. Department of Education and Missouri State University.

				
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