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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 firstname.lastname@example.org. 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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