Forward Service Corporation Upward Bound JAM-Application Form

Thank you for your interest in applying to Forward Service Corporation’s Upward Bound JAM Program. The UBJAM staff is here to help if you have any questions or encounter any difficulties while completing this application.

Contact information:

UBJAM staff can be reached at:

Email: ubjam@fsc-corp.org

Phone: 608-640-8063

Instructions:

The application is comprised of 4 sections. Please fully complete each section before submitting. You can monitor your progress in the upper left corner of the application.

Saving the Application:

If you cannot complete the application in one session, you can save and complete later. When saving, you will be offered the opportunity to create an account – this is not required. You can skip this step and a link to your application will be sent to the email address you provide.

Submitting the Application:

When you complete the application, select review answers, and then select submit. You will be asked to verify that you are not a robot and will receive confirmation of submission. Once confirmation of submission appears on your screen you can exit the application.

Next Steps

The information collected on the application is required by program regulations and will be treated with the utmost respect and confidentiality. UBJAM staff will review the submitted application and contact you with next steps.

We look forward to working with you.
Application for Admission

Student Information
1. Full Legal Name:*

First NameMiddle NameLast Name
2. Preferred First Name:
Pronouns:
3. Home Address: *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Check if Mailing Address is the same as Home Address

My mailing address is the same as my home address.
4. Mailing Address if different from above:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
5a. Current Age:*
5b. Birth Date:*

MonthDayYear
mm-dd-yyyy
6. Sex:*

MaleFemalePrefer not to answer
6b. Gender:
7a. Student Cell Phone:*
(999)999-9999
7b. Student Home Phone:*
(999)999-9999
8. Preferred Email: *
example@example.com
9. I am a student at:*
Other School*
10. Current Grade*
10a. Are you Hispanic or Latinx?*

YesNo
10b. Ethnicity
11. Please identify your race (choose all that apply):*

American Indian/Alaskan NativeAsianBlack or African AmericanWhiteNative Hawaiian or Other Pacific IslanderNone of the above
Student’s Primary Spoken Language*

EnglishSpanishOther (specify)
12. Primary home language:
13. Disability Disclosure: Applicants with disabilities or any other barriers are encouraged to self-disclose their disability in the space provided below. This information is voluntary and for reporting purposes only. All information will be kept confidential and will not be used to deny you services.

Yes, I would like to disclose a disabilityNo, I would not like to disclose a disability
14. If yes, please explain any accommodation you require:
15. Are your grades as good as they could be? If not, why aren’t they as good as they could be?
16. My strongest school subject is:
17. My most challenging school subject is:
18. Two careers I find interesting are:
19. What are your current plans for after high school? Is there anything that could prevent you from going to and succeeding in college?
20. Why do you want to be in this program?
21. What do you like to do (hobbies, sports, extracurricular activities)?
22. Tell us about a person who has had an influence on your life:
Disability Disclosure: Applicants with disabilities or any other barriers are encouraged to self-disclose their disability in the space provided below. This information is voluntary and for reporting purposes only. All information will be kept confidential and will not be used to deny you services.*

Yes, I would like to disclose a disabilityNo, I would not like to disclose a disability
If yes, please explain any accommodations you require:
1. I feel my grades are (check all that apply):*

lower than they should beaverageabove averagea poor indication of my abilitiesan accurate reflection of my abilities
2. Are your grades as good as they could be?*

YesNo
2a. If “no”, why are your grades not as good as they could be?

3. On a scale of 1-5 (1=very poor, 5=very good), I rate my ability in each of these subjects as follows:*

	1 (Very Poor)	2	3 (Average)	4	5 (Very Good)
English
Math
Foreign Language (e.g., Spanish, French, German)
Science
Social Studies (e.g., History, Government)

4. Two careers I find interesting are:*

	Career
1
2

5. While in high school, I plan to take the following number of years for each class below:*

	1	2	3	4	5
English
Math
Foreign Language (e.g., Spanish, French, German)
Science
Social Studies (e.g., History, Government)

6. After high school, I think I have the ability to attend (check all that apply):*

Trade School/Technical College2-Year College4-Year CollegeNo further schoolingOther (specify)
7. In the classroom, I (check all that apply):*

ask few questionscan't wait for class to be overask many questionsdo not pay attentionam shyinteract well with my teachersam disruptiveinteract well with my classmatesdo not participateparticipate in classroom discussions
8. Last year, I was absent from school (excused and unexcused): *

less than 1 week1-2 weeks2-4 weeksmore than 4 weeks
9. When I’m with classmates I tend to feel (check all that apply):*

stupidanxiousoutgoing, talkativedislikedquietrespectedlike a followersmarthappytrustedlike an outsiderpopularshyvery confidentlike a leaderbored
10. Check all circumstances which might prevent you from attending college (check all that apply):*

Lack of financial aidHousing concernsFamily obligationsLack of transportationPoor gradesLack of money for living expensesLack of motivationLack of emotional supportNo one to help me through the processParents/Guardians do not want me to attend
11. Rate how much you like school:*

1 (Dislike very much)23 (OK)45 (Like very much)
12. Rate how you think teachers care about you as a student:*

1 (Dislike very much)23 (OK)45 (Like very much)
13. If you took a field trip with Upward Bound, what is the maximum number of nights away from home you think you would be comfortable?*

012345+
14. Do you believe you will attend the on-campus, six-week summer program?*

YesNoUnsure
15. Why do you want to be in the Upward Bound program?*
16. Thinking about areas of your life outside of the classroom:
16a. What do you consider one of your personal strengths?*
16b. What do you consider one of your personal weaknesses?*
16c. How do you think the summer program will benefit you?*
17. What are your current plans for after high school? Is there anything that may prevent you from going to and succeeding in college?*
18. Do you think you will graduate from your current high school?*

YesNo
18a. If "no", why not?
19. Tell us about a person who had a big influence on your life? What character traits best describe them?*

Contact Information
PARENT / LEGAL GUARDIAN / RESPONSIBLE PERSON
(designated above)
Relationship to Student
Name

First NameMiddle InitialLast Name
Is the address the same as the student's?

YesNo
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile/Home Phone
(999)999-9999
Alternate Phone
(999)999-9999
Work Phone
(999)999-9999
Email
example@example.com
Additional Contact
Relationship to Student
Name

First NameMiddle InitialLast Name
Is the address the same as the student's?

YesNo
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile/Home Phone
(999)999-9999
Alternate Phone
(999)999-9999
Work Phone
(999)999-9999
Email
example@example.com

Authorization to Disclose Information to Forward Service Corporation
Student's Name*

First NameLast Name
Student's Date of Birth*

MonthDayYear
mm-dd-yyyy
WHAT: I voluntarily authorize and request disclosure (including paper, oral, and electronic interchange) of all education records and other information directly or indirectly related to my child’s education and career development. This includes specific permission to release:
- Progress records, including official student academic/administrative records (identifying information, grade level completed, grades, class rank, attendance records, and group aptitude and achievement test results)
- Medical and/or related health records
- Psychological evaluations or social work reports
- Law enforcement records
- Multidisciplinary team evaluations and related reports
- Individual education programs
- Behavioral records
- National Student Clearinghouse data for enrollment verification and tracking purposes
Other (specify):
FROM WHOM: School district my child is enrolled (please name):*
Other School*
TO WHOM: Forward Service Corporation employees assigned to the program

PURPOSE: To determine program eligibility, to develop and implement an program plan, and to evaluate progress in the program for the student named above.
For all participants regardless of age:
Student's Name*

First NameLast Name
Student's Signature*

Clear
Signature Date*

MonthDayYear
mm-dd-yyyy
For all participants under the age of 18:
Parent/Legal Guardian/Other Name

First NameLast Name
Signature of Parent/Legal Guardian/Other

Clear
Signature Date

MonthDayYear
mm-dd-yyyy