Marshall University-WV-UB-Application Form

Marshall University Upward Bound
Application

Upward Bound is a federally funded program for high school students whose purpose is to motivate and prepare them for higher education. Rising freshmen through seniors are eligible for our program. We are interested in students who demonstrate the ability to be successful in college. Serving students in Cabell, Lincoln and Wayne Counties, we offer tutoring, counseling and workshops. During the summer program, students have the opportunity to live on the Marshall University campus, travel, participate in sports, social and cultural activities, and take academic as well as elective classes. As a part of the Federal TRiO Programs, Upward Bound has a well-established record of helping students achieve academic as well as personal success. Upward Bound is an equal opportunity program and does not discriminate on the basis of race, religion, national origin, gender or disability. Any concerns regarding discrimination will be handled by the Director of Upward Bound.

Important Reminders to Speed the Processing of Your Upward Bound Application:
- Check to make sure that you have attached a copy of your parent's income tax statement (Form 1040, 1040A, or 1040EZ detailing Taxable Income) if they filed for income tax. If your parents did not file an income tax form last year because income received was not taxable, please have a statement prepared detailing the source(s) of income received. Please submit the statement to us as an attachment or fax it to (304) 696-3166. If you have questions about this, talk with your In-school Coordinator or contact the Upward Bound office at (304) 696-6462.
- Once you have provided all the necessary information to the Upward Bound Program, your application will be reviewed along with grades and test scores received from their school. Missing information will cause a delay. We will let you know if the information collected qualifies you for the Upward Bound Program. Once this occurs, it will be necessary for you and a parent to be interviewed by one of our staff members. Also, three completed evaluation sheets from personal references and/or school staff will need to be submitted to us to complete the application. Blank evaluation forms will be provided to you.
- Though you may qualify for Upward Bound, it may be necessary to place you on an alternate list if there are no openings at the time. Do not be discouraged! Students leave the program because they move, resign, or graduate from high school. When someone leaves Upward Bound, we replace him or her with a person from our alternate list.
- Remember, if you have any questions, talk with your In-school Coordinator or contact the Upward Bound office at (304) 696-6462. Our fax number is (304) 696-3166 if you wish to fax any information to us.
Upward Bound
Marshall University
One John Marshall Drive
Huntington, WV 25755
(304) 696-6462
(304) 696-3166 (fax)
lacy13@marshall.edu
Application Checklist
- Fill out and sign all areas of the application.
- Attach a copy of parent(s)’ income tax statement (Form 1040, 1040A, or 1040EZ detailing Taxable Income), if filed.
- If parents did not file an income tax form last year, because income was not taxable, then parent must have a statement prepared stating that they had no taxable income and detailing the source(s) of income received. The signed statement needs to be submitted to us.
- Make sure all references/evaluations are completed by either a teacher, counselor, or principal when blank forms are provided to you after review of your application

Personal Information
Student Name*

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Date of Birth

MonthDayYear
mm-dd-yyyy
Student Social Security Number
999-99-9999
Student Email address*
example@example.com
Home Phone
(999)999-9999
Student Cell
(999)999-9999
High School
Grade
Parent or Guardian Name

First NameLast Name
Relationship
Cell
(999)999-9999
Add'l Parent or Guardian Name

First NameLast Name
Relationship
Cell
(999)999-9999
Student Gender

MaleFemale
U.S. Citizen

YesNo
Race

CaucasianAfrican AmericanAmerican IndianHispanic or LatinAsianOther
Are you in another TRIO Program?

HATSEATSTRIONo

Please list the name, complete address (including zip code), and telephone number of three personal references. The references should be from the community and/or business leaders such as: teachers, employers, clergymen, friends of the family, lawyers, doctors, postmasters, etc.

	Name	Address	Zip	Phone Number
1
2
3

Financial Statement
The financial information requested below is needed to determine the eligibility of this applicant for the Upward Bound program. This information must be provided and will be kept confidential. This information should be for the parent/guardian who claims the student as a dependent.

If you filed an income tax return for last year or the year before, we will need a copy of your income tax statement (Form 1040, 1040A or 1040EZ) showing your taxable income. Please download the statement as an attachment to this application or fax it to (304) 696-3166.

If you were not required to file an income tax return, we request a statement detailing the family's main source(s) of non-taxable income. Please download the signed statement as an attachment or fax it to (304) 696-3166.
If you were not required to file an income tax form, check below the source(s) of income your family receives

Social SecurityPublic AssistanceBlack Lung BenefitsMiner's Retirement BenefitsVeteran's BenefitsVocational RehabilitationOther

Educational Goals
Educational Plans

I am undecided about my educational goalsI have no plan to continue my education after high school
After high school, I plan to continue my education at

Community CollegeCollege or UniversityTechnical or Vocational SchoolMilitary
Please list two ways the Upward Bound Program will be able to benefit you on your college journey and why?
1.
2.
What do you expect to gain from the Upward Bound Program?
List below the job(s) you can see yourself in at the age of 30, and explain the reason for your choice(s).
Do you have a part-time job? Where? How many hours a week do you work?
What are some special interests and hobbies you enjoy?
Tutoring Needs
Please check the area(s) below in which you would need tutoring assistance.

ScienceMathEnglish/SpeechSocial StudiesForeign LanguageNot Needed at This TimeOther

Current Class Schedule

	Class	Time	Teacher	Room #
1
2
3
4
5
6
7

Student Assessment Questionnaire
Name (Print)

First NameLast Name
School
Grade

Questionnaire

	Yes	No	Questions and Comments
1. Are you interested and motivated in going to college?
2. Did either of your natural or adoptive parents graduate from a four-year college?
3. Do you need assistance or tips for textbook reading, note-taking, test-taking, or study skills?
4. Are you failing classes and willing to seek tutoring to improve your grades if needed?
5. Would you attend tutoring after school and/or on weekends?
6. Do you know what classes you need to graduate from high school and to enroll in college?
7. Are you taking the classes you need to graduate from high school?
8. Have you ever been to a college campus?
9. Do you need financial assistance (loans, grants, scholarships) to be able to attend college?
10. Do you have any knowledge of the student financial aid and scholarships that might be available to you?
11. Do your parents understand the college admissions and financial aid process?
12. Do you know what your career choice is?
13. Do you know where to find career information?
14. Do you know what postsecondary program you will need to enroll in to reach this career goal?
15. Would you like more information related to your career choice?
16. Do you need help with registration, studying for, paying for, or taking the ACT and/or SAT College Entrance Exams? If you do not know what these tests are, please check yes.
17. Do your parents support your desire to go to college?
18. Have you participated in service learning or volunteer activities?
19. Do you currently have a job?

Personal Records Release Form
I give my permission for {highSchool} High School to release all grades and records of my child, {main_name}, to the Marshall University Upward Bound Program. I understand that these records and grades are to be held in the strictest confidence. These records will be used to determine my child’s academic strengths and weaknesses.
If not parent, please explain the relationship and authority.
Signature of Parent or Guardian

Clear
Date

MonthDayYear
mm-dd-yyyy

Parent Agreement to Participate
I give permission for my child, {main_name}, to participate fully in the Upward Bound Program at Marshall University. This participation includes scheduled academic and summer program activities and trips. I further grant permission for any medical and dental care authorized by a qualified physician. I will give full cooperation to the Upward Bound staff and encourage my child to abide by the rules of participation and to remain an active participant in the program.
If not parent, please explain the relationship and authority.
Signature of Parent or Guardian

Clear
Date

MonthDayYear
mm-dd-yyyy

Photolikeness Release
I authorize the Upward Bound Program at Marshall University to photograph or film my child, {main_name}, and consent to the use of his/her likeness in any publications, educational materials, advertising, news media, video and World Wide Web materials, and I acknowledge the university’s right to crop or treat the photograph at its discretion.
Signature of Parent or Guardian

Clear
Date

MonthDayYear
mm-dd-yyyy

Student Commitment to Participate
I, {main_name}, agree to participate in the Upward Bound Program at Marshall University. I understand that this involves active participation in activities during the school year and in the six-week summer program. School activities include monthly activities at the campus of Marshall University and weekly meetings with the In-School Coordinator at my school.
Signature of Student

Clear
Date

MonthDayYear
mm-dd-yyyy

Permission to Provide Contact Information
I authorize the Upward Bound program at Marshall University to provide my student's contact information to colleges, trade schools, and other educational organizations from which they could benefity receiving various notices.
Signature of Parent or Guardian

Clear
Date

MonthDayYear
MM-DD-YYYY

Father

Mother

Tutoring Needs