Western Kentucky University-UB-Application Form

UPWARD BOUND APPLICATION

The following application requires information and signatures from both student and a parent/guardian. Student and parent/guardian must be present to complete the application. All information must be true and accurate. Submitting false statements or forged signatures will make the applicant ineligible for the WKU Upward Bound program.

Student Needs Assessment
Upward Bound requires a teacher or counselor to complete a recommendation form. Please see https://www.wku.edu/upwardbound/apply.php for a link to the form. Please include the name of the teacher you will ask to complete this recommendation.

First NameLast Name
What do you plan to do after you graduate from high school?

WorkCommunity College4-year Institution (College or University)MilitaryTrade/Vocational SchoolOther

Please list the colleges, universities or technical schools you are most interested in attending

	Name of School
1
2
3

Please list the careers or occupation you are most interested in:

	Name of Career or Occupation
1
2
3

Please check all the academic areas in which you need assistance (you may check more than one)*

English/LiteratureMathematicsScienceForeign languageSocial StudiesOther
Please check all areas in which you need assistance (you may check more than one):*

Study skillsTime managementTest-taking skillsCareer DevelopmentCollege planningACT/SAT PreparationScholarship/Financial AidComputersTutoring (list subject areas below)
Subject areas for tutoring

Certifications and Signatures
This section must be completed by the student and the Parent/Guardian. Please check each box to each statement below, and sign and date on the appropriate lines at the bottom.

I/We understand that the completion of this application does not guarantee acceptance in the UB program.I/We understand that information provided on this application will be held in confidence by the UB program.I/We understand that the information provided on this application is true and correct to the best of my/our knowledge.I/We authorize the release of my school records (transcripts, test scores) to the UB program.I/We authorize the release and exchange of student financial aid information from colleges and federal government to the UB program.I/We authorize the release of college enrollment status to UB program.I/We understand that there is a zero tolerance policy for alcohol, illegal drugs, weapons, contact of a sexual nature, harassing, disrespectful, or threatening behaviors.I/We authorize the use of my image and/or statements in UB publications, media releases, and social media platforms about the UB program.
This section must be completed by the student and the Parent/Guardian.

Applicant: I understand the purpose of the Upward Bound program, which is to prepare participants to successfully complete high school and enroll in and complete a program of post-secondary education. As part of my personal effort in this preparation, I commit to fully participate in the Upward Bound sponsored meetings and activities. I will comply with the rules and regulations of the program, and I am aware that failure to comply could result in dismissal from the program.

Parent: I understand the purpose of the Upward Bound program, which is to prepare participants to successfully complete a program of post-secondary education, and would like to have my child participate in all activities, including field trips. I also authorize the Upward bound staff to have access to the student’s academic records, to render medical aid if necessary, and I release Upward Bound from responsibility for any harm incurred by the student.
Parent/Guardian Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Student Signature

Clear
Date

MonthDayYear
mm-dd-yyyy

Student Essay
Please answer in complete sentences. Your answer will be considered in the application review process.
What would you like to gain from Upward Bound? What subjects, traits, or skills would you like to improve upon?
Upward Bound
Western Kentucky University
1906 College Heights Blvd.
Bowling Green, KY 42101-1098

Located in Jones Jaggers Hall, Room 109
Telephone: (270) 745-4873
Fax: (270) 745-2031
Website: www.wku.edu/upwardbound