Wittenberg University-UB-Application Form

Wittenberg University TRIO Application

Notable Alumni of TRIO Programs from around the country include Oprah Winfrey, John Quinones, Angela Bassett, Franklin Chang-Diaz, Donna Brazille, Henry Bonilla, Patrick Ewing, Viola Davis, and Dr. Bernard Harris

Oprah Winfrey, Upward Bound, attended Lincoln High School, Milwaukee, Wisconsin, Talk Show Host
John Quiñones, Upward Bound, St. Mary's University, correspondent for ABC news, "Prime Time Live"
Angela Bassett, Upward Bound, St. Petersburg Junior College, actress
Franklin Chang-Diaz, Student Support Services, University of Connecticut, first Latino astronaut
Donna Brazille, Upward Bound, Louisiana, Vice Chair of the Democratic National Committee and CNN Political Commentator
Henry Bonilla, Talent Search, former US Congressman, 23rd district of Texas
Patrick Ewing, MIT-Wellesley Upward Bound Program, former NBA Basketball Player
Viola Davis, Upward Bound and Student Support Services, Rhode Island College, Oscar nominated actress in the movie “The Help”
Dr. Bernard Harris, Ronald E McNair Scholars Program, Texas Tech, first African American astronaut

Raphael Gamaliel Warnock is an American pastor and politician serving as the junior United States senator from Georgia since 2021. A member of the Democratic Party, he assumed office on January 20, 2021.

Gwendolynne Sophia Moore is an American politician serving as the U.S. Representative for Wisconsin's 4th congressional district since 2005. In 2016, Moore was elected to serve as Caucus Whip of the Congressional Black Caucus for the 115th United States Congress. She is a member of the Democratic Party

Steve Pemberton. Growing up, Steve spent years in the foster care system, where he lived with one particularly brutal and abusive family. For 11 years he was physically and verbally assaulted, starved, and constantly taught that he was nothing. Somehow, he managed to escape that situation and not only survive, but go on to graduate from a top university, and become a bestselling author, speaker, philanthropist, and senior-level executive for the likes of Monster, Walgreens Boots Alliance, and Globoforce.

General Information
What is Upward Bound?
Upward Bound is a pre-college preparatory program that is designed to motivate and provide academic skills for students from first-generation college and low-income families who are interested in pursuing an educational program beyond high school.

Who is eligible?
Students who are eligible must be in the 9th, 10th or 11th grade. Students must obtain two letters of recommendations from either teachers, counselors, social service agencies or others who are well acquainted with their academic potential for success in college. In addition, eligible students must be from low-income or first-generation college families where neither parent has received a baccalaureate degree.

How can it help me?
Upward Bound gives the high school student an opportunity to learn first-hand what college life is all about and helps the student to develop those skills necessary to succeed in college. The program emphasizes reading, writing, math, study skills and science. Courses are taught by skilled instructors whose primary concern is the student. Personal, career and academic counseling is also provided.

What do you do in Upward Bound?
During the summer, Upward Bound students live on the campus of Wittenberg University for six weeks and participate in a variety of academic, social and cultural activities. During their regular school year, Upward Bound students are in weekly contact with Upward Bound staff members including teachers and tutor-counselors through classes, home visits, counseling sessions and tutorials. Upward Bound students also participate in recreational activities such as swimming, softball, volleyball and Ping-Pong. For cultural enrichment, Upward Bound students visit museums, attend plays, concerts and recitals and go on educational field trips.

Is there any cost involved?
All program services are provided free of charge.

What are some of the other services provided?
A. Academic advising- Helping you to schedule the proper courses to meet college entrance requirements.

B. Fee waivers for ACT and SAT tests- Helping you to meet the cost of taking the required college entrance examinations.

C. Career assessment- Helping you to decide what college and field of study are most suitable for you.

D. Financial aid assistance- Helping you to complete the necessary applications for admission and financial aid.

E. Paying the application fees- Helping you to meet the cost of paying for up to three college application fees of your choice.

F. College credit- Providing you the opportunity to receive college credit at Wittenberg University before your freshmen year of college.

More information can be obtained from the Upward Bound Program at Wittenberg University (327-7535).

Upward Bound is a Federally Funded Program.

Application Procedures
Complete application form accurately. Include all signatures. Attach the following to your application*:

Copy of your parent’s most recent 1040 tax form

Your most recent student photo

Step 1: Upload current 1040 Tax Form (or similar tax information). In order to do so, you will need to take a photo of your form or similar tax information and save it to your computer as an upload or picture.

Step 2: In order to upload a student photo, repeat step 1
1040 Tax Form

Browse Files

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Student Photo

Browse Files

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Health Information
Please indicate below any pertinent health information we should be aware of (i.e. allergies, handicaps, medications, illnesses, etc.).

Personal Information
Name*

First NameMiddle InitialLast Name
Soc. Sec. #*
999-99-9999
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Cell Phone #*
(999)999-9999
Student Email Address*
example@example.com
Sex (Check one)*

MaleFemale
Date of Birth*

MonthDayYear
mm-dd-yyyy
Home Phone #*
(999)999-9999
Race (Check one)*

African-AmericanWhiteHispanicOther
U.S. Citizen*

YesNo
Do you or your parent(s) have a visa?*

YesNo
Current Enrollment Status*

Enrolled in Secondary SchoolWorking towards high school G.E.D.Not enrolled, planning to return to school
Name of school currently attending*
Location*
Name of school you will attend next year*
Location*
Type of school*

PublicPrivate
Current year in school*

8th9th10th11th
Student's most likely date of graduation from high school*
Month/Year
Which best describes your current or last high school academic program*

VocationalGeneralRemedialCollege Prep
What is your GPA on a scale of 4.00*
On a scale of*

4.00100.00
What do you plan to do after you graduate from High School? (Check all that apply)*

Attend a four-year collegeAttend a Community College (2 year degree)Enroll in a technical college programEnlist in the militaryGet a jobAttend a trade schoolOther
Have you taken the Ohio Graduation Test? *

YesNo

Ohio Graduation Tests*

	Pass	Fail
Math
Writing
Science
Reading
Social Studies

Give two (2) names of a middle school or high school teacher, counselor or coach whom we may contact for a character reference
Name*

First NameLast Name
School*
Telephone Number*
(999)999-9999
Name*

First NameLast Name
School*
Telephone Number*
(999)999-9999
Do you work after school or on the weekends?*

YesNo
What person or persons influenced your life most and in what ways?*
If you could change one part of your life, what would you change?*
What do you think you will be doing ten years from now?*
Whom do you know who is already enrolled in Upward Bound?*
What are some of your interests?*
What do you expect from Upward Bound?*
What do you consider to be your strong points?*
School activities (athletics, hobbies, clubs, interest areas, etc.)*
School awards received*
What are your academic strengths?*
What are your academic weaknesses?*
What do you consider as weaknesses in your personality?*
Whom do you confide in when you are feeling troubled?*
Does your son/daughter receive Special Education Services, for example, Individualized Education Plan (I.E.P.), 504 Accommodations, etc.? If so, who is your case manager and what is their telephone number?*

Confidential Family Data Section
The personal information you give to Upward Bound is sent to the federal government (Department of Education). The information is protected by the Privacy Act. No one may see the information unless working with or for the Upward Bound Program or specifically authorized to see the information. The information is necessary to determine if you are eligible to participate in the program and assists in measuring your success. The Department of Education has authority to gather information to help make Upward Bound a better program (20 USC 1231a). If you do not give this information to the Upward Bound program, you cannot receive any benefits from the program.
Name of Male Parent/Guardian

First NameLast Name
Social Security Number
999-99-9999
Name of Female Parent/ Guardian

First NameLast Name
Social Security Number
999-99-9999
Your Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student lives with

MotherFatherMother & FatherGuardianGrandparentOther
Your employer
Salary per Week
Your spouse's employer
Salary per Week

Do you receive income from the following?

	No	Yes	Amount per month
A.D.C.
Welfare
Social Security
Pension
Unemployment
Alimony & Child Support
Other (State)

Total number of persons supported on above income

List all persons who live in your home

	Name	Relationship	Age	Occupation & Employer	Salary
1
2
3
4
5
6

List the name of a relative or friend who will always know your address but does not live with you
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone #
(999)999-9999
Highest education level achieved by parent(s)

ElementaryJunior HighHigh SchoolCollege
Name of College
No. of years in college
Degree received
Marital Status

MarriedDivorcedSeparatedSingleWidowedOther
Student primarily lives with
Parent/Guardian Name

First NameLast Name

Consent
As Parent/Guardian of the student named below, I give my permission for my child to participate in the Wittenberg University Upward Bound Program. I have read this complete application and all answers are correct to the best of my knowledge. I attest to that fact by affixing my signature to this statement.
Signature of Parent/Guardian

Clear
Date

MonthDayYear
mm-dd-yyyy
Student

First NameLast Name

Student Statement
Your Name

First NameLast Name
Today's Date

MonthDayYear
mm-dd-yyyy
Grade (Check one)

8th9th10th11th
Please write a statement below telling why you are applying to the Upward Bound Program and why you wish to participate.
Please note that during the Summer Program, your son/daughter will not be excused to attend summer camps, family reunions, church related activities and other recreational activities that would conflict with weekly class attendance. However, weekend activities are always optional.

Find us on Facebook for pictures and Updates or visit us on the web at www.5wittenberg.edu/academics/upward_bound for more information
Wittenberg University TRIO Upward Bound Program
Record Access Authorization
Parent Name

First NameLast Name
Name of Student

First NameLast Name
INSTRUCTIONS: Parent/Guardian: Please complete this form and return it to:
Wittenberg University TRIO Upward Bound Program
P.O. Box 720
Springfield, Ohio 45501

I, {parentName}, hereby authorize Representatitives of the Wittenberg University TRIO Upward Bound Program to have full access to the following information from the record of: {nameOf114}
- Counselor/Teacher Evaluation
- Grades
- Attendance Record
- Truancy and Demerit Records
- Transcripts & Disciplinary Record
- Results of ACT, SAT, and Standardized Reading, Math, and Intelligence Tests
- Individualized Educational Plan (IEP)
- 504 Accommodations
- Class Schedule
Student ID#
Signature of Parent/Guardian

Clear
Wittenberg University's TRIO Upward Bound Program

Parental Statement

I, {parentName}, agree for my son/daughter {nameOf114}, to participate in Upward Bound subject to the following stipulations:

Academic Year Program

I understand that {nameOf114}, is to participate in:
- College Placement Activities (seniors only)
- Tutoring (at least one evening per week)
- Remedial workshops (if necessary)
- Cultural activities (at least one per month)
- Recreational activities (as scheduled)
Summer Program

I understand that during the summer program my son/daughter will not be excused from the following activities for any reason:
- Academic classes
- Remedial workshops
- Study tables
- Cultural activities
- Field trips
- Recreational activities
Except for 1) personal illness or 2) death in the family (must be documented)

While the Upward Bound Program wholeheartedly supports strong family life, no student will be excused from Upward Bound classes or activities to participate in family reunions.

I understand and agree to all conditions listed above and I acknowledge the same by affixing my signature below.
Parent/Guardian Signature

Clear
Date signed

MonthDayYear
mm-dd-yyyy
WITTENBERG UNIVERSITY'S TRIO UPWARD BOUND PROGRAM

MEDICAL AND EMERGENCY INFORMATION
Student Name

First NameLast Name
The law requires that before medical services can be preformed for a person under 18 years of age, permission of the parent or guardian must be secured. In the event of serious illness or accident, every effort will be made to contact parents or guardians. However, in the event that delay in medical or surgical treatment might be detrimental to the health of the student, authorization for consultation and treatment by physicians is requested. Your signature will serve as authorization for such treatment.
Doctor's Name:

First NameLast Name
Doctor's Phone Number:
(999)999-9999
Do you have a health card (A.D.C., Welfare, Medicaid?)

NoYes
Card Number:
Name of an adult other than parent/guardian with whom you live and whom we can contact in case of emergency:
Name

First NameLast Name
Phone Number (with area code)
(999)999-9999
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I, {parentName}, hereby authorize the staff of Wittenberg University to obtain any health examinations, inoculations, treatments, or emergency care that they may, in their judgment, deem necessary for my son/daughter or for my ward while s/he is in residence at Wittenberg University as a participant in the Upward Bound Program.

I agree to hold Wittenberg University and/or its staff free from any claims or suits for damages, for any injury or complications whatsoever which may result from the above procedures.
Date

MonthDayYear
mm-dd-yyyy
Parent/Guardian Signature

Clear
Witness Signature

Clear
Student Signature

Clear
Wittenberg University TRIO Upward Bound Program

Mental Health Record Access Authorization
Does your child currently attend mental health counseling?

YesNo
If yes, please complete the section below.

INSTRUCTIONS: Parent/Guardian: Please complete this form and return to the Upward Bound Office.
Parent/Guardian Name

First NameLast Name
I, {parentguardianName142}, hereby authorize

Representatives of the Wittenberg University TRIO Upward Bound Program to have full access to my child’s mental health/counseling history. Records may be obtained from the following health professionals:
- Counselor
- Behavioral Therapist
- Psychiatrist or Psychotherapist
- Psychologist
- Social Worker
Name of Student

First NameLast Name
Signature of Parent(s)/Guardian(s)

Clear
WITTENBERG TRIO UPARD BOUND

STUDENT CONTRACT

I, {nameOf144}, enter the TRIO Upward Bound Program at Wittenberg University with the following commitments:
1. I will attend my high school classes regularly;
2. I will schedule classes appropriate to preparation for college or technical school;
3. I will meet with Upward Bound tutors regularly;
4. I will attend the Upward Bound Summer Program; while in the Summer Program I will attend classes regularly and punctually;
5. I will participate fully in all counselling and testing programs that the Upward Bound Program may require;
6. I will meet as necessary with special tutors to strengthen my skills in areas where testing or grades reveal that I am weak (this is in addition to weekly sessions with tutor counselor);
7. I will, upon request, provide the Upward Bound Program with information such as grades, schedules and release forms;
8. I will assume full responsibility for attending one cultural activity each month during the academic year;
9. I will graduate from high school;
10. I will go to college, university, technical school, business college or nursing school;
11. I will conduct myself in a way that will bring pride and unity to the program.
By my signature I indicate that I have read the above responsibilities carefully and fully intend to abide by each obligation as stated in this contract.
Date

MonthDayYear
mm-dd-yyyy
Student's Signature

Clear