Western Reserve University-UB

Upward Bound Program

Case Western Reserve University

Application for Admission
- Dear Applicant:
  
  You have made a wise decision to seek admission to the Upward Bound Program at Case Western Reserve University.Your interest in Upward Bound means that you plan to attend college after you graduate from high school. Graduation from high school and college attendance are significant accomplishments for you, your family, and your community. Upward Bound at Case Western Reserve University can help you with your academic work and assist you in gaining admission to college.
  
  As you can imagine, many students are interested in the Upward Bound Program at Case. Unfortunately, each year we have a limited number of openings, and admission to the program is very competitive. I mention this not to scare you away, but rather to let you know how important it is to complete this application in a way that will give me a good idea of who you are and what you think your academic and personal needs are. Unless you present yourself well on paper, I cannot make a good decision about your application.
  
  Like a regular admission application, our Upward Bound student application asks you a lot of questions. It takes time to prepare the application. Many enthusiastic students take an application but never complete it or turn it in. Obviously, these students never get selected. Therefore, I urge you to complete the application and turn it in on time.
  
  Once you turn in your application, you should receive a notice about your eligibility or about your interview. If you meet the eligibility requirements, you will be personally interviewed by me or another Upward Bound staff person before a final decision is made.
  
  I look forward to reading your application and meeting you in person.
  
  Sincerely,
  
  Erica Calderon,
  Director of TRIO Programs
- Date
  
  MonthDayYear
  mm-dd-yyyy
- Name*
  
  First NameMILast Name
- Social Security Number *
  999-99-9999
- Gender
  
  MaleFemale
- Address
  
  Street Address
  
  Apt. #
  
  CityState
  
  Zip Code
- Parent Telephone Number *
  (999)999-9999
- Date of Birth
  
  MonthDayYear
  mm-dd-yyyy
- Student's Email Address*
  example@example.com
- Ethnic Origin
  
  African-AmericanHispanic/Latin AmericanAsian AmericanNative AmericanCaucasianOther
- Are you
  
  a U.S. Citizenan eligible non-citizen (please provide copy of immigration document)Other
- What is the primary language(s) spoken in your home?
  
  EnglishEnglish/SpanishOther
- Current High School
- Current Grade
  
  91011
- GPA
- What do you plan to do after you graduate from High School? (Check all that apply)
  
  Attend a University (four-year degree)Enroll in a technical college programGet a jobAttend a Community College (two-year degree)Enlist in the militaryAttend a trade schoolOther
- Have you taken the Ohio Graduation Test?
  
  YesNo
- Are you currently active in any other TRIO Programs?
  
  YesNo
- If yes, which program?
- Why do you want to participate in Upward Bound?
- Student's Signature*
  
  Clear
- Date
  
  MonthDayYear
  mm-dd-yyyy
- Father/Male Guardian
  
  First NameMILast Name
- Highest educational level completed*
  
  High School (9-12)Associate’s DegreeBachelor’s Degree or beyond
- Mother/Female Guardian
  
  First NameMILast Name
- Highest educational level completed*
  
  High School (9-12)Associate’s DegreeBachelor’s Degree or beyond
- Marital Status
  
  MarriedDivorcedSeparatedSingleWidowedOther
- Student Primarily Lives With (Parent/Guardian Name)
- Please complete all blanks. This should be completed by the parent/guardian with whom the student lives with, or by the parent/guardian providing at least 50% of student’s financial support.
- Mother's Occupation
- Mother's Work Number
  (999)999-9999
- Father's Occupation
- Father's Work Number
  (999)999-9999
- Please indicate your Annual Taxable or Non-Taxable Income below:*
  
  Below $19,140$19,141 - $25,860$25,861 - $32,580$32,581 - $39,300$39,301 - $46,020$46,021 - $52,740$52,741 - $59,460$59,461 - $66,180$66,181 and up
- Number of Adults in Household
- Number of Children in Household
- ADDITIONAL INFORMATION: (To be completed ONLY if it applies to your current situation.)
- If you are under 18, are you a ward of the State of Ohio (foster care placement)
  
  YesNo
- Have you aged out of the foster care system?
  
  YesNo
- Presently, where are you living? (Check one)
  
  ShelterWith more than one family in a house or apartmentin a motel, car, or campsitewith friends or family members (other than parent or guardian)
- Has a documented learning disability?
  
  YesNo
- Currently on an Individualized Education Plan (I.E.P.)
  
  YesNo
- I hereby certify that the information in this application is correct and true to the best of my knowledge and herby authorize the Upward Bound Program at Case Western Reserve University to release and receive information to assist my son/daughter with his/her educational planning. I understand that any false or misleading information may result in disqualification of the applicant.
- Parent/Guardian's Name
  
  First NameLast Name
- Signature*
  
  Clear
- Date
  
  MonthDayYear
  mm-dd-yyyy
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Relationship
- Emergency Number
  (999)999-9999
- Cell Number
  (999)999-9999
- Parent/Guardian e-mail address (optional):
  example@example.com
- I hereby grant permission for___________________________ (Name of School) to disclose and provide to the Case Western Reserve University Upward Bound Program upon request transcripts, grades, attendance record, schedules, truancy and demerit records, results of ACT, SAT, PSAT, proficiency scores and standardized reading and mathematics tests which are contained in the academic records of:
- Name of School
- Student's Name
  
  First NameLast Name
- Social Security Number
  999-99-9999
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Parent/Guardian Signature*
  
  Clear
- Date
  
  MonthDayYear
  mm-dd-yyyy